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Thursday, 17 May 2018

The health promoting conversations intervention for families with a critically ill relative: A pilot study

 by S. gren, A. Eriksson, M. Fredrikson, G. Hollman-Frisman, L. Orwelius  



After intensive care unit treatment, patients often have prolonged impairments that affect their physical, cognitive and mental health. Family members can face overwhelming and emotionally challenging situations and their concerns and needs must be addressed.


We investigated the outcomes of pilot randomised control trial, a nurse-led family intervention, Health Promoting Conversations, which focused on family functioning and wellbeing in families with a critically ill member.

Study design

This randomised controlled pilot study used a pre-test, post-test design with intervention and control groups to investigate the outcomes of the nurse-led intervention in 17 families.

Outcome measures

The Health Promoting Conversations intervention was evaluated using validated instruments that measure family functioning and family wellbeing: the General Functioning sub-scale from the McMaster Family Assessment Device; the Family Sense of Coherence, the Herth Hope Index, and the Medical Outcome Short-Form Health Survey. Descriptive and analytical statistical methods were used to analyse the data.


After 12 months, the intervention group reported better family functioning than the control group. The intervention group also had better social functioning and mental health after 12 months.


This intervention may improve family wellbeing by improving family function, reducing stress, and promoting better mental health.

Use of the CAM-ICU during daily sedation stops in mechanically ventilated patients as assessed and experienced by intensive care nurses – A mixed-methods study

by Else Berit Steinseth, Sevald Høye, Reidun Hov  

Mechanically ventilated patients are at risk of developing delirium, which increases mortality and prolongs their stay in the Intensive Care Unit (ICU).



Mechanically ventilated patients are at risk of developing delirium, which increases mortality and prolongs their stay in the Intensive Care Unit (ICU).


To investigate the assessment of delirium by ICU nurses and their experiences of using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) in mechanically ventilated patients during daily sedation stops.


The study employed an explanatory sequential mixed-methods design. The data (n = 30) were collected by two nurses who assessed the same patient (n = 15) using the tool. Data from the nurses’ assessments were analysed by means of frequency analysis, while the interviews were analysed phenomenographically using Dahlgren and Fallberg’s seven categories.


Four pairs of nurses made similar assessments, three pairs had differing assessments and in eight pairs, one of the nurses did not fill in the form properly. The interviews revealed variations in ICU nurses’ preparation for, views on and use of the CAM-ICU.


Assessment and use of the CAM-ICU revealed variations, indicating the necessity of identifying barriers within the ICU team. ICU nurses need training in the use of the CAM-ICU and support in their decision–making. The individual nurse must take responsibility for updating their knowledge and for following guidelines.

The communication experience of tracheostomy patients with nurses in the intensive care unit: A phenomenological study

by Angela Tolotti, Annamaria Bagnasco, Gianluca Catania, Giuseppe Aleo, Nicola Pagnucci, Lucia Cadorin, Milko Zanini, Gennaro Rocco, Alessandro Stievano, Franco A. Carnevale, Loredana Sasso  

Intensive Critical Care Nursing – In press



To describe the experience and sources of comfort and discomfort in tracheostomy patients, when they communicate with nurses in the Intensive Care Unit.

Research methodology/design

Benner’s interpretive phenomenology. Data were collected through: a) semi-structured interviews conducted with the patients after leaving the intensive care unit; b) participant observation; c) situated interviews with intensive care nurses.


The intensive care unit of a hospital in Northern Italy.


Eight patients and seven nurses were included in this study. Two main themes were identified 1) feeling powerless and frustrated due to the impossibility to use voice to communicate; 2) facing continual misunderstanding, resignation, and anger during moments of difficulty and/or communication misunderstandings. The main communication discomfort factors were: struggling with not knowing what was happening, feeling like others had given up on me, living in isolation and feeling invisible. The main comfort factors were: being with family members, feeling reassured by having a call bell nearby and nurses' presence.


This study highlights the important role of communication in tracheostomy patients in intensive care and how closely it is linked to all the aspects of a person’s life, which cannot be underestimated as just not being able to use one’s voice.

Sedation Intensity in the First 48 Hours of Mechanical Ventilation and 180-Day Mortality: A Multinational Prospective Longitudinal Cohort Study*

by Shehabi, Yahya; Bellomo, Rinaldo; Kadiman, Suhaini; Ti, Lian Kah; Howe, Belinda; Reade, Michael C.; Khoo, Tien Meng; Alias, Anita; Wong, Yu-Lin; Mukhopadhyay, Amartya; McArthur, Colin; Seppelt, Ian; Webb, Steven A.; Green, Maja; Bailey, Michael J.; for the Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators and the Australian and New Zealand Intensive Care Society Clinical  

Objectives: In the absence of a universal definition of light or deep sedation, the level of sedation that conveys favorable outcomes is unknown. We quantified the relationship between escalating intensity of sedation in the first 48 hours of mechanical ventilation and 180-day survival, time to extubation, and delirium. Design: Harmonized data from prospective multicenter international longitudinal cohort studies Setting: Diverse mix of ICUs. Patients: Critically ill patients expected to be ventilated for longer than 24 hours. Interventions: Richmond Agitation Sedation Scale and pain were assessed every 4 hours. Delirium and mobilization were assessed daily using the Confusion Assessment Method of ICU and a standardized mobility assessment, respectively. Measurements and Main Results: Sedation intensity was assessed using a Sedation Index, calculated as the sum of negative Richmond Agitation Sedation Scale measurements divided by the total number of assessments. We used multivariable Cox proportional hazard models to adjust for relevant covariates. We performed subgroup and sensitivity analysis accounting for immortal time bias using the same variables within 120 and 168 hours. The main outcome was 180-day survival. We assessed 703 patients in 42 ICUs with a mean (SD) Acute Physiology and Chronic Health Evaluation II score of 22.2 (8.5) with 180-day mortality of 32.3% (227). The median (interquartile range) ventilation time was 4.54 days (2.47–8.43 d). Delirium occurred in 273 (38.8%) of patients. Sedation intensity, in an escalating dose-dependent relationship, independently predicted increased risk of death (hazard ratio [95% CI], 1.29 [1.15–1.46]; p < 0.001, delirium hazard ratio [95% CI], 1.25 [1.10–1.43]), p value equals to 0.001 and reduced chance of early extubation hazard ratio (95% CI) 0.80 (0.73–0.87), p value of less than 0.001. Agitation level independently predicted subsequent delirium hazard ratio [95% CI], of 1.25 (1.04–1.49), p value equals to 0.02. Delirium or mobilization episodes within 168 hours, adjusted for sedation intensity, were not associated with survival. Conclusions: Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation. These observations suggest that keeping sedation level equivalent to a Richmond Agitation Sedation Scale 0 is a clinically desirable goal.

Prompt Administration of Antibiotics and Fluids in the Treatment of Sepsis: A Murine Trial*

by Lewis, Anthony J.; Griepentrog, John E.; Zhang, Xianghong; Angus, Derek C.; Seymour, Christopher W.; Rosengart, Matthew R.

Objectives: Sepsis, the acute organ dysfunction caused by a dysregulated host response to infection, poses a serious public health burden. Current management includes early detection, initiation of antibiotics and fluids, and source control as necessary. Although observational data suggest that delays of even a few hours in the initiation of antibiotics or IV fluids is associated with survival, these findings are controversial. There are no randomized data in humans, and prior animal studies studied time from experimental manipulation, not from the onset of clinical features of sepsis. Using a recently developed murine cecal ligation and puncture model that precisely monitors physiologic deterioration, we hypothesize that incremental hourly delays in the first dose of antibiotics, in the first bolus of fluid resuscitation, or a combination of the two at a clinically relevant point of physiologic deterioration during polymicrobial sepsis will shorten survival. Design: Randomized laboratory animal experimental trial. Setting: University basic science laboratory. Subjects: Male C57BL/6J, female C57BL/6J, aged (40–50 wk old) male C57BL/6J, and BALB/C mice. Interventions: Mice (n = 200) underwent biotelemetry-enhanced cecal ligation and puncture and were randomized after meeting validated criteria for acute physiologic deterioration. Treatment groups consisted of a single dose of imipenem/cilastatin, a single bolus of 30 mL/kg fluid resuscitation, or a combination of the two. Mice were allocated to receive treatment at the time of meeting deterioration criteria, after a 2-hour delay or after a 4-hour delay. Measurements and Main Results: Hourly delays in the initiation of antibiotic therapy led to progressively shortened survival in our model (p < 0.001). The addition of fluid resuscitation was unable to rescue animals, which received treatment 4 hours after meeting enrollment criteria. Systemic inflammation was increased, and host physiology was increasingly deranged with hourly delays to antibiotics. Conclusions: We conclude that antibiotic therapy is highly time sensitive, and efforts should be made to deliver this critical therapy as early as possible in sepsis, perhaps extending into the first point of medical contact outside the hospital.

Danger Signals in the ICU

by Schenck, Edward J.; Ma, Kevin C.; Murthy, Santosh B.; Choi, Augustine M. K.  

Objectives: Sterile and infectious critical illnesses often result in vasoplegic shock and a robust systemic inflammatory response that are similar in presentation. The innate immune system is at the center of the response to both infectious and traumatic insults. Damage-associated molecular patterns are small molecules that are released from stressed or dying cells. Damage-associated molecular patterns activate pattern recognition receptors and coordinate the leading edge of the innate immune response. This review introduces the concept of damage-associated molecular patterns and how they activate a systemic inflammatory response, specifically in trauma, neurologic injury, and infection. It also explores how, when carried to extremes, damage-associated molecular patterns may even perpetuate multisystem organ failure. Data Sources: Basic and clinical studies were obtained from a PubMed search through August 2017. Study Selection: Articles considered include original articles, review articles, and conference proceedings. Data Extraction: An analysis of scientific, peer-reviewed data was performed. High quality preclinical and clinical studies adjudicated by the authors were included and summarized. Data Synthesis: Pattern recognition receptors respond to damage-associated molecular patterns and then activate inflammatory pathways. Damage-associated molecular patterns have been linked to the recruitment of sentinel leukocytes and the initiation of the inflammatory cascade. Damage-associated molecular patterns have been linked to many conditions in critical care illnesses. Preclinical models have added insight into how they may mediate distant organ dysfunction. Conclusions: Damage-associated molecular pattern activation and release is an important research for intensive care practitioners. It will add to our understanding of the phase and state of the innate immune response to an insult. Early work is encouraging. However, only with improved understanding of damage-associated molecular pattern activation and function, we can perhaps hope to target damage-associated molecular patterns as diagnostic and/or therapeutic modalities in the future.

Systematic Review and Meta-Analysis of Procalcitonin-Guidance Versus Usual Care for Antimicrobial Management in Critically Ill Patients: Focus on Subgroups Based on Antibiotic Initiation, Cessation, or Mixed Strategies*

by Lam, Simon W.; Bauer, Seth R.; Fowler, Robert; Duggal, Abhijit  

Objective: Numerous studies have evaluated the use of procalcitonin guidance during different phases of antibiotics management (initiation, cessation, or a combination of both) in patients admitted to ICUs. Several meta-analyses have attempted to generate an overall effect of procalcitonin-guidance on patient outcomes. However, combining studies from different phases of antibiotics management may not be appropriate due to the risk of clinical heterogeneity. The purpose of this systematic review and meta-analysis was to evaluate the effect of procalcitonin-guided strategies in different phases of antibiotics use. Data Sources: We searched MEDLINE and EMBASE from inception until November 1, 2017. Study Selection: We included randomized controlled trials that evaluated procalcitonin guidance compared with usual care for management of antibiotics in critically ill adult patients. Data Extraction: We extracted study details, patient characteristics, procalcitonin algorithm, and outcomes. Data Synthesis: We included 15 studies, from 1,624 abstracts identified based on our search strategy (three initiation, nine cessation, and three mixed). The pooled risk ratio for short-term mortality for the initiation, cessation, and mixed procalcitonin strategies were 1.00 (95% CI, 0.86–1.15,;p = 0.91), 0.87 (95% CI, 0.77–0.98; p = 0.02), and 1.01 (95% CI, 0.80–1.29; p = 0.93), respectively. Procalcitonin for cessation and mixed strategies was associated with decrease antibiotics duration (–1.26 d [p < 0.001] and –3.10 d [p =0.04], respectively). No differences were observed in other outcome measures. Conclusion: When evaluating all studies of procalcitonin-guided antibiotics management in critically ill patients, no difference in short-term mortality was observed. However, when only examining procalcitonin-guided cessation of antibiotics, lower mortality was detected. Future studies should focus specifically on procalcitonin for the cessation of antibiotics in critically ill patients.