Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study

Background Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. Methods This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. Results Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI − 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI − 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. Conclusions Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021)

Correlation study of SLC6A4 and ABCB1 gene polymorphisms with intraoperative remifentanil requirements of patients undergoing thyroidectomy

Introduction: Perioperative anesthetic and/or analgesic demands present considerable variation, and part of that variation appears to be genetic in origin. The aim of this study was to investigate the impact of common polymorphisms in SLC6A4 and ABCB1 genes, on the intra-operative consumption of remifentanil, as well as the postoperative analgesic needs, in patients subjected to minimal invasive thyroidectomy surgery. Materials and Methods: We conducted a prospective cohort study with 90 patients scheduled to undergo elective thyroidectomy, under total intravenous anesthesia achieved by target control infusion (TCI) of remifentanil. Postoperative analgesics were administered by protocol and as on-demand of the individual patient. Genotyping was established by PCR-RFLP methods. Genotyping data, intraoperative hemodynamics, and total consumption of remifentanil, as well as postoperative analgesic needs and pain perception, were recorded for each individual. Results: Intraoperative remifentany l consumption was not associated with any polymorphism. Patients with the ABCB1 3435TT genotype appeared to experience significantly less pain, up to one hour post-operatively, compared to C carriers [mean VAS (SD) at 1 h = 0.86 (1.22) vs. 2.42 (1.75); p = 0.017], a finding limited to those seeking rescue analgesic treatment (additional to the standard analgesics per protocol). The SLC6A4 polymorphisms did not have a significant effect on pain or analgesic needs. Conclusions: The ABCB1 C3435T polymorphism appears to affect post-operative perception of surgical pain among patients with low pain threshold who undergo minimally invasive thyroid surgery. The SLC6A4 polymorphisms did not show any effect. Future, larger studies involving more genes and more polymorphisms may reveal further, stronger associations between genetic substrate and peri-operative analgesic needs.Εισαγωγή: Οι περι-εγxειρητικές ανάγκες σε αναισθητικά ή/και αναλγητικά φάρμακα παρουσιάζουν αξιοσημείωτη διακύμανση και μέρος αυτής φαίνεται να είναι γενετικά καθοριζόμενο. Ο σκοπός της παρούσας μελέτης ήταν να διερευνήσει την επίδραση κοινών πολυμορφισμών των γονιδίων SLC6A4 και ABCB1, στις διεγχειρητικές απαιτήσεις σε ρεμιφεντανύλη καθώς και στις μετεγχειρητικές ανάγκες σε αναλγητικά, σε ασθενείς που υποβάλλονται σε εκλεκτικές επεμβάσεις ελάχιστα επεμβατικής θυρεοειδεκτομής. Υλικό και Μέθοδος: Πρόκειται για μία μελέτη παρατήρησης, τύπου κοόρτης, η οποία συμπεριέλαβε 90 ασθενείς που υποβλήθηκαν σε εκλεκτική θυρεοειδεκτομή, υπό γενική αναισθησία με σύστημα ελεγχόμενης έγχυσης στόχου (Target Controlled Infusion – TCI) ρεμιφεντανύλης. Μετεγχειρητικά τα αναλγητικά φάρμακα χορηγούνταν τόσο βάσει πρωτοκόλλου όσο και κατ΄επίκληση, αναλόγως του πόνου που αισθανόταν ο κάθε ασθενής. Ο καθορισμός του γονοτύπου έγινε με εφαρμογή καθιερωμένων μεθόδων PCR-RFLP. Για κάθε ασθενή έγινε καταγραφή του γονοτύπου, των διεγχειρητικών αιμοδυναμικών παραμέτρων, της συνολικής κατανάλωσης ρεμιφεντανύλης, των μετεγχειρητικών αναγκών σε αναλγητικά και της αντίληψης του πόνου (με την κλίμακα VAS).Αποτελέσματα: Οι διεγχειρητικές ανάγκες σε ρεμιφεντανύλη δεν συσχετίσθηκαν με κανέναν πολυμορφισμό. Οι ασθενείς με τον γονότυπο ABCB1 3435TT ένιωθαν στατιστικά σημαντικά λιγότερο μετεγχειρητικό πόνο μέχρι και μία ώρα μετά την επέμβαση, συγκριτικά με τους φορείς του C αλληλομόρφου [μέση κλίμακα VAS (SD) στην 1 ώρα = 0.86 (1.22) vs. 2.42 (1.75); p = 0.017], ένα εύρημα το οποίο περιοριστήκε μόνο στην ομάδα εκείνη των ασθενών που χρειάζονταν επιπρόσθετη αναλγητική αγωγή (επιπλέον της σταθερά χορηγούμενης βάσει πρωτοκόλλου). Οι πολυμορφισμοί του SLC6A4 δεν είχαν κάποια σημαντική επίδραση στην αντίληψη του πόνου ή στις ανάγκες σε αναλγητικά. Συμπεράσματα: Ο πολυμορφισμός ABCB1 C3435T φαίνεται να επηρεάζει την αντίληψη του μετεγχειρητικού χειρουργικού πόνου σε ασθενείς με χαμηλό ουδό πόνου, που υποβάλλονται σε ελάχιστα επεμβατική θυρεοειδεκτομή. Αντίθετα, οι πολυμορφισμοί του SLC6A4 δεν έδειξαν κάποια επίδραση. Μελλοντικές, μεγαλύτερες μελέτες, με περισσότερα γονίδια και περισσότερους πολυμορφισμούς ενδέχεται να αποκαλύψουν περαιτέρω και ισχυρότερες συσχετίσεις μεταξύ γενετικού υποβάθρου και περιεγχειρητικών αναγκών σε αναλγητικά φάρμακα

Pneumonia due to Ochrobactrum intermedium in an ICU patient

Ochrobactrum intermedium is recognized as a rare emerging opportunistic pathogen mostly related with bloodstream infections. In this report, we describe the first clinical case of pneumonia due to O. intermedium. The case involved a 71-year old tetraplegic man hospitalized for vertebral fractures after falling from a ladder

Perceptions of ethical decision-making climate among clinicians working in European and U.S. ICUs : differences between nurses and physicians

Objectives: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses' and physicians' rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses. Design: Prospective observational study. Setting: A total of 68 adult ICUs in 13 European countries and the United States. Subjects: ICU physicians and nurses. Interventions: None. Measurements and Main Results: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses' involvement at end-of-life, average without nurses' involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions. Conclusions: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies

COVID-19-Associated Pulmonary Aspergillosis (CAPA) in Northern Greece during 2020–2022: A Comparative Study According to the Main Consensus Criteria and Definitions

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) has emerged as an important complication among patients with acute respiratory failure due to SARS-CoV-2 infection. Almost 2.5 years since the start of the COVID-19 pandemic, it continues to raise concerns as an extra factor that contributes to increased mortality, which is mostly because its diagnosis and management remain challenging. The present study utilises the cases of forty-three patients hospitalised between August 2020 and February 2022 whose information was gathered from ten ICUs and special care units based in northern Greece. The main aim was to describe the gained experience in diagnosing CAPA, according to the implementation of the main existing diagnostic consensus criteria and definitions, and present the different classification of the clinical cases due to the alternative algorithms

Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort

Objectives: We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged- infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies. Methods: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries. Results: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT 65MIC (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving \u3b2-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P=0.012]. Additionally, in patients with a SOFA score of 65 9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P=0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P=0.025]. Conclusions: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infection

Co-infection and ICU-acquired infection in COIVD-19 ICU patients: a secondary analysis of the UNITE-COVID data set

Background: The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients.Methods: This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson's Chi-squared and continuous variables by Mann-Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the "full" matching method.Results: Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO.Conclusions: In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids