Human factors and ergonomics to improve performance in intensive care units during the COVID-19 pandemic

The COVID-19 pandemic has tested the very elements of human factors and ergonomics (HFE) to their maximum. HFE is an established scientific discipline that studies the interrelationship between humans, equipment, and the work environment. HFE includes situation awareness, decision making, communication, team working, leadership, managing stress, and coping with fatigue, empathy, and resilience. The main objective of HF is to optimise the interaction of humans with their work environment and technical equipment in order to maximise patient safety and efficiency of care. This paper reviews the importance of HFE in helping intensivists and all the multidisciplinary ICU teams to deliver high-quality care to patients in crisis situations

A survey of preferences for respiratory support in the intensive care unit for patients with acute hypoxaemic respiratory failure

Publisher Copyright: © 2023 The Authors. Acta Anaesthesiologica Scandinavica published by John Wiley & Sons Ltd on behalf of Acta Anaesthesiologica Scandinavica Foundation.Background: When caring for mechanically ventilated adults with acute hypoxaemic respiratory failure (AHRF), clinicians are faced with an uncertain choice between ventilator modes allowing for spontaneous breaths or ventilation fully controlled by the ventilator. The preferences of clinicians managing such patients, and what motivates their choice of ventilator mode, are largely unknown. To better understand how clinicians' preferences may impact the choice of ventilatory support for patients with AHRF, we issued a survey to an international network of intensive care unit (ICU) researchers. Methods: We distributed an online survey with 32 broadly similar and interlinked questions on how clinicians prioritise spontaneous or controlled ventilation in invasively ventilated patients with AHRF of different severity, and which factors determine their choice. Results: The survey was distributed to 1337 recipients in 12 countries. Of these, 415 (31%) completed the survey either fully (52%) or partially (48%). Most respondents were identified as medical specialists (87%) or physicians in training (11%). Modes allowing for spontaneous ventilation were considered preferable in mild AHRF, with controlled ventilation considered as progressively more important in moderate and severe AHRF. Among respondents there was strong support (90%) for a randomised clinical trial comparing spontaneous with controlled ventilation in patients with moderate AHRF. Conclusions: The responses from this international survey suggest that there is clinical equipoise for the preferred ventilator mode in patients with AHRF of moderate severity. We found strong support for a randomised trial comparing modes of ventilation in patients with moderate AHRF.Peer reviewe

Cardiac ultrasound: a true haemodynamic monitor?

Cardiac ultrasound has been used in the critically ill for more than thirty years. The technology has made enormous progression with respect to image quality and quantity, various Doppler techniques, as well as connectivity, the transfer of data and offline calculations. Some consider cardiac ultrasound as the stethoscope of the Twenty-first century. The potential of eye-balling moving cardiac structures gives undeniable power to this diagnostic and monitoring tool. The main shortcoming is the discontinuous mode of monitoring and the fact that optimal information acquisition can only be obtained when one is well-trained and experienced. Cardiac ultrasound has become an indispensable tool, especially in haemodynamically unstable patients. This review summarizes some important aspects of cardiac ultrasound with use of Doppler monitoring for assessment of the three most important pillars of haemodynamics, namely cardiac preload, afterload and contractile function.Cardiac ultrasound has been used in the critically ill for more than thirty years. The technology has made enormousprogression with respect to image quality and quantity, various Doppler techniques, as well as connectivity, the transferof data and offline calculations. Some consider cardiac ultrasound as the stethoscope of the Twenty-first century. Thepotential of eye-balling moving cardiac structures gives undeniable power to this diagnostic and monitoring tool.The main shortcoming is the discontinuous mode of monitoring and the fact that optimal information acquisitioncan only be obtained when one is well-trained and experienced. Cardiac ultrasound has become an indispensabletool, especially in haemodynamically unstable patients. This review summarizes some important aspects of cardiacultrasound with use of Doppler monitoring for assessment of the three most important pillars of haemodynamics,namely cardiac preload, afterload and contractile function

Initial resuscitation from severe sepsis: one size does not fit all

  Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. Barometric preload indicators, such as central venous pressure (CVP) or pulmonary artery occlusion pressure, can be persistently low or erroneously increased, as is the case in situations of increased intrathoracic pressure, as seen with the application of high positive end-expiratory pressure, or in situations with increased intra-abdominal pressure. Chasing a CVP of 8 to 12 mm Hg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation and all the deleterious effects on end-organ function associated with fluid overload. We will suggest the introduction of new variables and more dynamic measurements. During the initial resuscitation phase, it is equally important to assess fluid responsiveness, either with a passive leg raising manoeuvre or an end-expiratory occlusion test. The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.    Over recent decades many recommendations for the management of patients with sepsis and septic shock have been published, mainly as the Surviving Sepsis Campaign (SSC) guidelines. In order to use these recommendations at the bedside one must fully understand their limitations, especially with regard to preload assessment, fluid responsiveness and cardiac output. In this review we will discuss the evidence behind the bundles presented by the Surviving Sepsis Campaign and will try to explain why some recommendations may need to be updated. Barometric preload indicators, such as central venous pressure (CVP) or pulmonary artery occlusion pressure, can be persistently low or erroneously increased, as is the case in situations of increased intrathoracic pressure, as seen with the application of high positive end-expiratory pressure, or in situations with increased intra-abdominal pressure. Chasing a CVP of 8 to 12 mm Hg may lead to under-resuscitation in these situations. On the other hand, a low CVP does not always correspond to fluid responsiveness and may lead to over-resuscitation and all the deleterious effects on end-organ function associated with fluid overload. We will suggest the introduction of new variables and more dynamic measurements. During the initial resuscitation phase, it is equally important to assess fluid responsiveness, either with a passive leg raising manoeuvre or an end-expiratory occlusion test. The use of functional hemodynamics with stroke volume variation or pulse pressure variation may further help to identify patients who will respond to fluid administration or not. Furthermore, ongoing fluid resuscitation beyond the first 24 hours guided by CVP may lead to futile fluid loading. In patients that do not transgress spontaneously from the Ebb to Flow phase of shock, one should consider (active) de-resuscitation guided by extravascular lung water index measurements.

Critical care ultrasound in cardiac arrest. Technological requirements for performing the SESAME-protocol — a holistic approach

  The use of ultrasound has gained its place in critical care as part of our day-to-day monitoring tools. A better understanding of ultrasound techniques and recent publications including protocols for the lungs, the abdomen and the blood vessels has introduced ultrasound to the bedside of our ICU patients. However, we will prove in this paper that early machines, dating back more than 25 years, were perfectly able to do the job as compared to modern laptop machines with more features but few additional advantages. Ultrasound is not only a diagnostic tool, but should also be seen as an extension of the traditional physical examination. This paper will focus on the use of the SESAME-protocol in cardiac arrest. The SESAME-protocol suggests starting with a lung scan to rule out possible causes leading to cardiac arrest. Firstly, pneumothorax needs to be ruled out. Secondly, a partial diagnosis of pulmonary embolism is done following the BLUE-protocol. Thirdly, fluid therapy can be guided, following the FALLS-protocol. The SESAME-protocol continues by scanning the lower femoral veins to check for signs of deep venous thrombosis, followed by (or before, in case of trauma) the abdomen to detect massive bleeding. Next comes the pericardium, to exclude pericardial tamponade. Finally, a transthoracic cardiac ultrasound is performed to check for other (cardiac) causes leading to cardiac arrest. The emphasis is on a holistic approach, where ultrasound can be seen as the modern stethoscope needed by clinicians to complete the full physiological examination of their critically ill unstable patients.    The use of ultrasound has gained its place in critical care as part of our day-to-day monitoring tools. A better understanding of ultrasound techniques and recent publications including protocols for the lungs, the abdomen and the blood vessels has introduced ultrasound to the bedside of our ICU patients. However, we will prove in this paper that early machines, dating back more than 25 years, were perfectly able to do the job as compared to modern laptop machines with more features but few additional advantages. Ultrasound is not only a diagnostic tool, but should also be seen as an extension of the traditional physical examination. This paper will focus on the use of the SESAME-protocol in cardiac arrest. The SESAME-protocol suggests starting with a lung scan to rule out possible causes leading to cardiac arrest. Firstly, pneumothorax needs to be ruled out. Secondly, a partial diagnosis of pulmonary embolism is done following the BLUE-protocol. Thirdly, fluid therapy can be guided, following the FALLS-protocol. The SESAME-protocol continues by scanning the lower femoral veins to check for signs of deep venous thrombosis, followed by (or before, in case of trauma) the abdomen to detect massive bleeding. Next comes the pericardium, to exclude pericardial tamponade. Finally, a transthoracic cardiac ultrasound is performed to check for other (cardiac) causes leading to cardiac arrest. The emphasis is on a holistic approach, where ultrasound can be seen as the modern stethoscope needed by clinicians to complete the full physiological examination of their critically ill unstable patients.

The state of critical care ultrasound training in Europe: A survey of trainers and a comparison of available accreditation programmes

Background: Although critical care ultrasound (CCUS) in the Intensive Care Unit has been increasing exponentially for diagnostic and therapeutic purposes, the lack of a uniform formal training structure and programme has posed the question of whether scans have been appropriately performed or reported, and whether there exists proper clinical governance to ensure a high standard of care. Methods: An online survey was sent to the representatives of various national intensive care societies via the European Society of Intensive Care Medicine CoBaTrICE committee. A comparison between 5 worldwide accreditation programmes was also made. Results: Twenty-seven out of 42 countries replied our survey. Five countries had a nationally accredited programme in ICM Echocardiography while six were in the process of developing one. Three countries had a CCUS-accredited programme. Most had local programmes. Transthoracic echocardiography, lung and vascular ultrasound were considered essential. Although CCUS training programmes should incorporate a combination of theoretical and practical teaching, it is not clear which is the best format. The main barriers to delivering CCUS training included a lack of formally agreed competencies, as well as a lack of trainers and time. There is also a lack of agreement between the five accreditation programmes. Conclusions: There is a need for a well-structured and competent CCUS training program. The use of ultrasound in critical care for diagnostic and therapeutic purposes has been increasing exponentially. Once the remit of radiologists and cardiologists, point-of-care ultrasound and focused echocardiography is becoming an increasingly routine instrument for all acute specialties including intensive care medicine, despite the lack of evidence that it improves patient mortality in the ICU setting

Lung ultrasound in the critically ill (LUCI): A translational discipline

In the early days of ultrasound, it was not a translational discipline. The heart was claimed by cardiologists, with others, such as gynaecologists, urologists and vascular surgeons claiming their part while the rest was given to radiologists. Only recently, ultrasound transgressed and crossed the usual borders between the different disciplines, such as emergency and critical care medicine. The advent of portable machines in the early 1980s, allowed the critical care physician to perform bedside ultrasound, and the development of whole body critical care ultrasound (CCUS) was born. It may sound cynical that radiologists were the first to state that diagnostic sonography was truly the next stethoscope: poorly utilized by many but understood by few. Exactly the same radiologists then abandoned the use of ultrasound outside the radiology department, leaving a vast domain to other disciplines eager to welcome the modern stethoscope. In this review, we list the possibilities of lung ultrasound as a translational holistic discipline