Acute and Critical Care

Original Article

Trauma
Selection of appropriate reference creatinine estimate for acute kidney injury diagnosis in patients with severe trauma: Kangho Lee, Dongyeon Ryu, Hohyun Kim, Sungjin Park, Sangbong Lee, Chanik Park, Gilhwan Kim, Sunhyun Kim, Nahyeon Lee; Acute Crit Care. 2023;38(1):95-103. Published online February 27, 2023; DOI: https://doi.org/10.4266/acc.2022.01046

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Abstract PDF: Background
In patients with severe trauma, the diagnosis of acute kidney injury (AKI) is important because it is a predictive factor for poor prognosis and can affect patient care. The diagnosis and staging of AKI are based on change in serum creatinine (SCr) levels from baseline. However, baseline creatinine levels in patients with traumatic injuries are often unknown, making the diagnosis of AKI in trauma patients difficult. This study aimed to enhance the accuracy of AKI diagnosis in trauma patients by presenting an appropriate reference creatinine estimate (RCE). Methods: We reviewed adult patients with severe trauma requiring intensive care unit admission between 2015 and 2019 (n=3,228) at a single regional trauma center in South Korea. AKI was diagnosed based on the current guideline published by the Kidney Disease: Improving Global Outcomes organization. AKI was determined using the following RCEs: estimated SCr75-modification of diet in renal disease (MDRD), trauma MDRD (TMDRD), admission creatinine level, and first-day creatinine nadir. We assessed inclusivity, prognostic ability, and incrementality using the different RCEs. Results: The incidence of AKI varied from 15% to 46% according to the RCE used. The receiver operating characteristic curve of TMDRD used to predict mortality and the need for renal replacement therapy (RRT) had the highest value and was statistically significant (0.797, P<0.001; 0.890, P=0.002, respectively). In addition, the use of TMDRD resulted in a mortality prognostic ability and the need for RRT was incremental with AKI stage. Conclusions: In this study, TMDRD was feasible as a RCE, resulting in optimal post-traumatic AKI diagnosis and prognosis.

Review Article

Nursing
Theoretical definition of nurse–conscious mechanically ventilated patient communication: a scoping review with qualitative content analysis: Arezoo Mohamadkhani Ghiasvand, Meimanat Hosseini, Foroozan Atashzadeh-Shoorideh; Acute Crit Care. 2023;38(1):8-20. Published online February 27, 2023; DOI: https://doi.org/10.4266/acc.2022.01039

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Abstract PDF Supplementary Material: Providing critical nursing care for conscious mechanically ventilated patients is mediated via effective communication. This study aimed to identify and map the antecedents, attributes, consequences, and definition of nurse–conscious mechanically ventilated patient communication (N-CMVPC). This scoping review was conducted by searching the Cochrane Library and the CINAHL, EMBASE, PubMed, Web of Science, and Scopus databases, between 2001 and 2021. The keywords queried included "nurses," "mechanically ventilated patients," "mechanical ventilation," "intubated patients," "communication," "interaction," "relationships," "nurse–patient communication," "nurse–patient relations," "intensive care units," and "critical care." Studies related to communication with healthcare personnel or family members were excluded. The results indicated that N-CMVPC manifests as a set of attributes in communication experiences, emotions, methods, and behaviors of the nurse and the patient and is classified into three main themes, nurse communication, patient communication, and quantitative-qualitative aspects. N-CMVPC is a complex, multidimensional, and multi-factor concept. It is often nurse-controlled and can express itself as questions, sentences, or commands in the context of experiences, feelings, and positive or negative behaviors involving the nurse and the patient.

Original Articles

Infection
Study of the gut microbiome as a novel target for prevention of hospital-associated infections in intensive care unit patients: Suzan Ahmed Elfiky, Shwikar Mahmoud Ahmed, Ahmed Mostafa Elmenshawy, Gehad Mahmoud Sultan, Sara Lotfy Asser; Acute Crit Care. 2023;38(1):76-85. Published online February 23, 2023; DOI: https://doi.org/10.4266/acc.2022.01116

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Abstract PDF: Background
Hospital-acquired infections (HAIs) are increasing due to the spread of multi-drugresistant organisms. Gut dysbiosis in an intensive care unit (ICU) patients at admission showed an altered abundance of some bacterial genera associated with the occurrence of HAIs and mortality. In the present study, we investigated the pattern of the gut microbiome in ICU patients at admission to correlate it with the development of HAIs during ICU stay. Methods: Twenty patients admitted to an ICU with a cross-matched control group of 30 healthy subjects of matched age and sex. Quantitative SYBR green real-time polymerase chain reaction was done for the identification and quantitation of selected bacteria. Results: Out of those twenty patients, 35% developed ventilator-associated pneumonia during their ICU stay. Gut microbiome analysis showed a significant decrease in Firmicutes and Firmicutes to Bacteroidetes ratio in ICU patients in comparison to the control and in patients who developed HAIs in comparison to the control group and patients who did not develop HAIs. There was a statistically significant increase in Bacteroides in comparison to the control group. There was a statistically significant decrease in Bifidobacterium and Faecalibacterium prausnitzii and an increase in Lactobacilli in comparison to the control group with a negative correlation between Acute Physiology and Chronic Health Evaluation (APACHE) II score and Firmicutes to Bacteroidetes and Prevotella to Bacteroides ratios. Conclusions: Gut dysbiosis of patients at the time of admission highlights the importance of identification of the microbiome of patients admitted to the ICU as a target for preventing of HAIs

Infection
Predicting factors associated with prolonged intensive care unit stay of patients with COVID-19: Won Ho Han, Jae Hoon Lee, June Young Chun, Young Ju Choi, Youseok Kim, Mira Han, Jee Hee Kim; Acute Crit Care. 2023;38(1):41-48. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.01235

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Abstract PDF: Background
Predicting the length of stay (LOS) for coronavirus disease 2019 (COVID-19) patients in the intensive care unit (ICU) is essential for efficient use of ICU resources. We analyzed the clinical characteristics of patients with severe COVID-19 based on their clinical care and determined the predictive factors associated with prolonged LOS. Methods: We included 96 COVID-19 patients who received oxygen therapy at a high-flow nasal cannula level or above after ICU admission during March 2021 to February 2022. The demographic characteristics at the time of ICU admission and results of severity analysis (Sequential Organ Failure Assessment [SOFA], Acute Physiology and Chronic Health Evaluation [APACHE] II), blood tests, and ICU treatments were analyzed using a logistic regression model. Additionally, blood tests (C-reactive protein, D-dimer, and the PaO2 to FiO2 ratio [P/F ratio]) were performed on days 3 and 5 of ICU admission to identify factors associated with prolonged LOS. Results: Univariable analyses showed statistically significant results for SOFA score at the time of ICU admission, C-reactive protein level, high-dose steroids, mechanical ventilation (MV) care, continuous renal replacement therapy, extracorporeal membrane oxygenation, and prone position. Multivariable analysis showed that MV care and P/F ratio on hospital day 5 were independent factors for prolonged ICU LOS. For D-dimer, no significant variation was observed at admission; however, after days 3 and 5 days of admission, significant between-group variation was detected. Conclusions: MV care and P/F ratio on hospital day 5 are independent factors that can predict prolonged LOS for COVID-19 patients.

Trauma
Association of Glasgow coma scale and endotracheal intubation in predicting mortality among patients admitted to the intensive care unit: Nader Markazi Moghaddam, Mohammad Fathi, Sanaz Zargar Balaye Jame, Mohammad Darvishi, Morteza Mortazavi; Acute Crit Care. 2023;38(1):113-121. Published online February 22, 2023; DOI: https://doi.org/10.4266/acc.2022.00927

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Abstract PDF: Background
We assessed predictors of mortality in the intensive care unit (ICU) and investigated if Glasgow coma scale (GCS) is associated with mortality in patients undergoing endotracheal intubation (EI). Methods: From February 2020, we performed a 1-year study on 2,055 adult patients admitted to the ICU of two teaching hospitals. The outcome was mortality during ICU stay and the predictors were patients’ demographic, clinical, and laboratory features. Results: EI was associated with a decreased risk for mortality compared with similar patients (adjusted odds ratio [AOR], 0.32; P=0.030). This shows that EI had been performed correctly with proper indications. Increasing age (AOR, 1.04; P<0.001) or blood pressure (AOR, 1.01; P<0.001), respiratory problems (AOR, 3.24; P<0.001), nosocomial infection (AOR, 1.64; P=0.014), diabetes (AOR, 5.69; P<0.001), history of myocardial infarction (AOR, 2.52; P<0.001), chronic obstructive pulmonary disease (AOR, 3.93; P<0.001), immunosuppression (AOR, 3.15; P<0.001), and the use of anesthetics/sedatives/hypnotics for reasons other than EI (AOR, 4.60; P<0.001) were directly; and GCS (AOR, 0.84; P<0.001) was inversely related to mortality. In patients with trauma surgeries (AOR, 0.62; P=0.014) or other surgical categories (AOR, 0.61; P=0.024) undergoing EI, GCS had an inverse relation with mortality (accuracy=82.6%, area under the receiver operator characteristic curve=0.81). Conclusions: A variety of features affected the risk for mortality in patients admitted to the ICU. Considering GCS score for EI had the potential of affecting prognosis in subgroups of patients such as those with trauma surgeries or other surgical categories.

Pediatrics
Characteristics and timing of mortality in children dying in pediatric intensive care: a 5-year experience: Edin Botan, Emrah Gün, Emine Kübra Şden, Cansu Yöndem, Anar Gurbanov, Burak Balaban, Fevzi Kahveci, Hasan Özen, Hacer Uçmak, Ali Genco Gençay, Tanil Kendirli; Acute Crit Care. 2022;37(4):644-653. Published online November 11, 2022; DOI: https://doi.org/10.4266/acc.2022.00395

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Abstract PDF

Background
Pediatric intensive care units (PICUs), where children with critical illnesses are treated, require considerable manpower and technological infrastructure in order to keep children alive and free from sequelae. Methods: In this retrospective comparative cohort study, hospital records of patients aged 1 month to 18 years who died in the study PICU between January 2015 and December 2019 were reviewed. Results: A total of 2,781 critically ill children were admitted to the PICU. The mean±standard deviation age of 254 nonsurvivors was 64.34±69.48 months. The mean PICU length of stay was 17 days (range, 1–205 days), with 40 children dying early (<1 day of PICU admission). The majority of nonsurvivors (83.9%) had comorbid illnesses. Children with early mortality were more likely to have neurological findings (62.5%), hypotension (82.5%), oliguria (47.5%), acidosis (92.5%), coagulopathy (30.0%), and cardiac arrest (45.0%) and less likely to have terminal illnesses (52.5%) and chronic illnesses (75.6%). Children who died early had a higher mean age (81.8 months) and Pediatric Risk of Mortality (PRISM) III score (37). In children who died early, the first three signs during ICU admission were hypoglycemia in 68.5%, neurological symptoms in 43.5%, and acidosis in 78.3%. Sixty-seven patients needed continuous renal replacement therapy, 51 required extracorporeal membrane oxygenation support, and 10 underwent extracorporeal cardiopulmonary resuscitation. Conclusions: We found that rates of neurological findings, hypotension, oliguria, acidosis, coagulation disorder, and cardiac arrest and PRISM III scores were higher in children who died early compared to those who died later.

Citations

Citations to this article as recorded by

Descriptive and Clinical Characteristics of Nonsurvivors in a Tertiary Pediatric Intensive Care Unit in Turkey: 6 Years of Experience
Zeynep Karakaya, Merve Boyraz, Seyma Koksal Atis, Servet Yuce, Muhterem Duyu
Journal of Pediatric Intensive Care.2023;[Epub] CrossRef

Review Article

Basic science and research
Barriers and facilitators in the provision of palliative care in adult intensive care units: a scoping review: Christantie Effendy, Yodang Yodang, Sarah Amalia, Erna Rochmawati; Acute Crit Care. 2022;37(4):516-526. Published online October 18, 2022; DOI: https://doi.org/10.4266/acc.2022.00745

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Abstract PDF: The provision of palliative care in the intensive care unit (ICU) is increasing. While some scholars have suggested the goals of palliative care to not be aligned with the ICU, some evidence show benefits of the integration. This review aimed to explore and synthesize research that identified barriers and facilitators in the provision of palliative care in the ICU. This review utilized Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Review guidelines based on population, concept, and context. We searched for eligible studies in five electronic databases (Scopus, PubMed, ProQuest, Science Direct, and Sage) and included studies on the provision of palliative care (concept) in the ICU (context) that were published in English between 2005–2021. We describe the provision of palliative care in terms of barriers and facilitators. We also describe the study design and context. A total of 14 papers was included. Several barriers and facilitators in providing palliative care in the ICU were identified and include lack of capabilities, family boundaries, practical issues, cultural differences. Facilitators of the provision of palliative care in an ICU include greater experience and supportive behaviors, i.e., collaborations between health care professionals. This scoping review demonstrates the breadth of barriers and facilitators of palliative care in the ICU. Hospital management can consider findings of the current review to better integrate palliative care in the ICU.

Original Articles

Infection
The prognostic impact of rheumatoid arthritis in sepsis: a population-based analysis: Lavi Oud, John Garza; Acute Crit Care. 2022;37(4):533-542. Published online October 6, 2022; DOI: https://doi.org/10.4266/acc.2022.00787

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Abstract PDF Supplementary Material: Background
Rheumatoid arthritis (RA) is associated with increased risk of sepsis and higher infection-related mortality compared to the general population. However, the evidence on the prognostic impact of RA in sepsis has been inconclusive. We aimed to estimate the population-level association of RA with short-term mortality in sepsis. Methods: We used statewide data to identify hospitalizations aged ≥18 years in Texas with sepsis, with and without RA during 2014–2017. Hierarchical logistic models with propensity adjustment (primary model), propensity score matching, and multivariable logistic regression without propensity adjustment were used to estimate the association of RA with short-term mortality among sepsis hospitalizations. Results: Among 283,025 sepsis hospitalizations, 7,689 (2.7%) had RA. Compared to sepsis hospitalizations without RA, those with RA were older (aged ≥65 years, 63.9% vs. 56.4%) and had higher burden of comorbidities (mean Deyo comorbidity index, 3.2 vs. 2.7). Short-term mortality of sepsis hospitalizations with and without RA was 26.8% vs. 31.4%. Following adjustment for confounders, short-term mortality was lower among RA patients (adjusted odds ratio [aOR], 0.910; 95% confidence interval [CI], 0.856–0.967), with similar findings on alternative models. On sensitivity analyses, short-term mortality was lower in RA patients among sepsis hospitalizations aged ≥65 years and those with septic shock, but not among those admitted to intensive care unit (ICU; aOR, 0.990; 95% CI, 0.909–1.079). Conclusions: RA was associated, unexpectedly, with lower short-term mortality in septic patients. However, this “protective” association was driven by those patients without ICU admission. Further studies are warranted to confirm these findings and to examine the underlying mechanisms.

Infection
Ability of a modified Sequential Organ Failure Assessment score to predict mortality among sepsis patients in a resource-limited setting: Bodin Khwannimit, Rungsun Bhurayanontachai, Veerapong Vattanavanit; Acute Crit Care. 2022;37(3):363-371. Published online August 4, 2022; DOI: https://doi.org/10.4266/acc.2021.01627

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Abstract PDF Supplementary Material: Copyright © 2022 The Korean Society of Critical Care Medicine This is an Open Access article distributed under the terms of Creative Attributions Non- Commercial License (https://creativecommons. org/li-censes/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.accjournal.org 363 INTRODUCTION Sepsis is a life-threatening condition and constitutes major health care problems around the world [1,2]. Sepsis was associated with nearly 20% of all global deaths, and the majority of sepsis cases occurred in low- or middle-income countries [1]. In 2017, the World Health Organization recommended actions to reduce the global burden of sepsis [2]. Sepsis has been defined as acute life-threatening organ dysfunction due to dysregulation of host responses to Background: Some variables of the Sequential Organ Failure Assessment (SOFA) score are not routinely measured in sepsis patients, especially in countries with limited resources. Therefore, this study was conducted to evaluate the accuracy of the modified SOFA (mSOFA) and compared its ability to predict mortality in sepsis patients to that of the original SOFA score.
Methods
Sepsis patients admitted to the medical intensive care unit of Songklanagarind Hospital between 2011 and 2018 were retrospectively analyzed. The primary outcome was all-cause in-hospital mortality.
Results
A total of 1,522 sepsis patients were enrolled. The mean SOFA and mSOFA scores were 9.7±4.3 and 8.8±3.9, respectively. The discrimination of the mSOFA score was significantly higher than that of the SOFA score for all-cause in-hospital mortality (area under the receiver operating characteristic curve, 0.891 [95% confidence interval, 0.875–0.907] vs. 0.879 [0.862–0.896]; P<0.001), all-cause intensive care unit (ICU) mortality (0.880 [0.863–0.898] vs. 0.871 [0.853–0.889], P=0.01) and all-cause 28-day mortality (0.887 [0.871–0.904] vs. 0.874 [0.856–0.892], P<0.001). The ability of mSOFA score to predict all-cause in-hospital and 28-day mortality was higher than that of the SOFA score within the subgroups of sepsis according to age, sepsis severity and serum lactate levels. The mSOFA score was demonstrated to have a performance similar to the original SOFA score regarding the prediction of mortality in sepsis patients with cirrhosis or hepatic dysfunction.
Conclusions
The mSOFA score was a good alternative to the original SOFA core in predicting mortality among sepsis patients admitted to the ICU.

Pediatrics
Clinical implications of discrepancies in predicting pediatric mortality between Pediatric Index of Mortality 3 and Pediatric Logistic Organ Dysfunction-2: Eui Jun Lee, Bongjin Lee, You Sun Kim, Yu Hyeon Choi, Young Ho Kwak, June Dong Park; Acute Crit Care. 2022;37(3):454-461. Published online July 29, 2022; DOI: https://doi.org/10.4266/acc.2021.01480

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Abstract PDF: Background
Pediatric Index of Mortality 3 (PIM 3) and Pediatric Logistic Organ Dysfunction-2 (PELOD-2) are validated tools for predicting mortality in children. Research suggests that these tools may have different predictive performance depending on patient group characteristics. Therefore, we designed this study to identify the factors that make the mortality rates predicted by the tools different.
Methods
This retrospective study included patients (<18 years) who were admitted to a pediatric intensive care unit from July 2017 to May 2019. After defining the predicted mortality of PIM 3 minus the predicted mortality rate of PELOD-2 as “difference in mortality prediction,” the clinical characteristics significantly related to this were analyzed using multivariable regression analysis. Predictive performance was analyzed through the Hosmer-Lemeshow test and area under the receiver operating characteristic curve (AUROC).
Results
In total, 945 patients (median [interquartile range] age, 3.0 [0.0–8.0] years; girls, 44.7%) were analyzed. The Hosmer-Lemeshow test revealed AUROCs of 0.889 (χ2=10.187, P=0.313) and 0.731 (χ2=6.220, P=0.183) of PIM 3 and PELOD-2, respectively. Multivariable linear regression analysis revealed that oxygen saturation, partial pressure of CO2, base excess, platelet counts, and blood urea nitrogen levels were significant factors. Patient condition-related factors such as cardiac bypass surgery, seizures, cardiomyopathy or myocarditis, necrotizing enterocolitis, cardiac arrest, leukemia or lymphoma after the first induction, bone marrow transplantation, and liver failure were significantly related (P<0.001).
Conclusions
Both tools predicted observed mortality well; however, caution is needed in interpretation as they may show different prediction results in relation to specific clinical characteristics.

Neurology
The effects of hypomagnesemia on delirium in middle-aged and older adult patients admitted to medical intensive care units: Joong-Yub Kim, Hyo Jin Lee, Hong Yeul Lee, Sang-Min Lee, Jinwoo Lee, Tae Yun Park; Acute Crit Care. 2022;37(3):407-414. Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00164

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Abstract PDF

Background
In critically ill patients, the most common manifestation of brain dysfunction is delirium, which is independently associated with higher morbidity and mortality. While electrolyte imbalance is one of the precipitating factors, the impact of hypomagnesemia on the incidence of delirium remains unknown.
Methods
We retrospectively analyzed patients admitted to the medical intensive care unit (ICU) of a tertiary referral center between January and June 2020. Patients with ICU stay ≥48 hours and aged 40–85 years were included. The primary outcome was cumulative incidence of delirium in the ICU. Patients were divided into two groups based on serum magnesium level at ICU admission. Multivariable Cox proportional hazards regression analysis was performed, and covariates were selected using the least absolute shrinkage and selection operator (LASSO) method.
Results
A total of 109 patients included 43 (39.4%) women and had a median age of 69.0 years (interquartile range [IQR], 60.0–76.0 years). The median magnesium level was 1.7 mg/dl (IQR, 1.5–1.9 mg/dl), and the cumulative incidence of delirium was 32.1% (35 patients). Hypomagnesemia was independently associated with delirium (adjusted hazard ratio [aHR], 2.12; 95% confidence interval [CI], 1.03–4.38), along with prior use of immunosuppressants (aHR, 3.08; 95% CI, 1.46–6.48) or benzodiazepines (aHR, 4.02; 95% CI, 1.54–10.50), body mass index (aHR, 0.93; 95% CI, 0.84–1.02), and alcohol history (aHR, 1.68; 95% CI, 0.74–3.80).
Conclusions
In critically ill adults, hypomagnesemia increases the risk of delirium by more than two-fold compared to patients with normal magnesium level.

Citations

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Hypomagnesemia and incident delirium in hospitalized older persons
Virginia Boccardi, Sara Ercolani, Rocco Serra, Valentina Bubba, Alessandro Piccolo, Michela Scamosci, Alfredo Villa, Carmelinda Ruggiero, Patrizia Mecocci
Aging Clinical and Experimental Research.2023;[Epub] CrossRef

Neurology
Cytokine profiles in intensive care unit delirium: Ryan J. Smith, Christian Lachner, Vijay P. Singh, Shubham Trivedi, Biswajit Khatua, Rodrigo Cartin-Ceba; Acute Crit Care. 2022;37(3):415-428. Published online June 20, 2022; DOI: https://doi.org/10.4266/acc.2021.01508

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Abstract PDF

Background
Neuroinflammation causing disruption of the blood-brain barrier and immune cell extravasation into the brain parenchyma may cause delirium; however, knowledge of the exact pathophysiologic mechanism remains incomplete. The purpose of our study was to determine whether cytokine profiles differ depending on whether delirium occurs in the setting of sepsis, coronavirus disease 2019 (COVID-19), or recent surgery.
Methods
This prospective observational cohort study involved 119 critically ill patients admitted to a multidisciplinary intensive care unit (ICU) during 2019 and 2020. Delirium was identified using the validated confusion assessment method for the ICU. Multiple delirium risk factors were collected daily including clinical characteristics, hospital course, lab values, vital signs, surgical exposure, drug exposure, and COVID-19 characteristics. Serums samples were collected within 12 hours of ICU admission and cytokine levels were measured.
Results
The following proinflammatory cytokines were elevated in our delirium population: tumor necrosis factor (TNF)-α, interleukin (IL)-6, IL-18, C-C motif ligand (CCL) 2, CCL3, C-X-C motif chemokine ligand (CXCL)1, CXCL10, IL-8, IL-1 receptor antagonist, and IL-10. Analysis of relative cytokine levels in those patients that developed delirium in the setting of sepsis, COVID-19, and recent surgery showed elevations of CCL2, CXCL10, and TNF-α in both the sepsis and COVID-19 group in comparison to the postsurgical population. In the postsurgical group, granulocyte colony-stimulating factor was elevated and CXCL10 was decreased relative to the opposing groups.
Conclusions
We identify several cytokines and precipitating factors known to be associated with delirium. However, our study suggests that the cytokine profile associated with delirium is variable and contingent upon delirium precipitating factors.

Citations

Citations to this article as recorded by

Systemic interleukin-6 inhibition ameliorates acute neuropsychiatric phenotypes in a murine model of acute lung injury
Faizan Anwar, Nicklaus A. Sparrow, Mohammad Harun Rashid, Gena Guidry, Michael M. Gezalian, Eric J. Ley, Maya Koronyo-Hamaoui, Itai Danovitch, E. Wesley Ely, S. Ananth Karumanchi, Shouri Lahiri
Critical Care.2022;[Epub] CrossRef

Case Reports

Pulmonary
Digital tomography in the diagnosis of a posterior pneumothorax in the intensive care unit: Shauni Wellekens, Nico Buls, Johan De Mey, Vincent Van Nieuwenhove, Jeroen Cant, Joop Jonckheer; Received December 24, 2021 Accepted February 4, 2022 Published online June 10, 2022; DOI: https://doi.org/10.4266/acc.2021.01802 [Epub ahead of print]

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Abstract PDF: Portable chest radiography is a valuable tool in the intensive care unit. However, the supine position causes superposition of anatomical structures resulting in less reliable detection of certain abnormalities. Recently, a portable digital tomosynthesis (pDTS) prototype with a modified motorized X-ray device was developed. Our aim is to compare the diagnostic value of pDTS to standard bedside chest radiography in the diagnosis of a posterior pneumothorax. A modified motorized x-ray device was developed to perform 15 radiographic projections while translating the X-ray tube 25 cm (10 cm ramp up and 15 cm during X-ray exposure) with a total radiation dose of 0.54 mSv. This new technique of pDTS was performed in addition to standard bedside chest X-ray in a patient with a confirmed posterior hydropneumothorax. The images were compared with the standard bedside chest X-ray and computed tomography (CT) images by two experienced radiologists. The posterior hydropneumothorax previously identified with CT was visible on tomosynthesis images but not with standard bedside imaging. Combining the digital tomosynthesis technique with the portable x-ray machine could increase the diagnostic value of bedside chest radiography for the diagnosis of posterior pneumothoraces, while avoiding intrahospital transport and limiting radiation exposure compared to CT.

Cardiology
Successful neural modulation of bedside modified thoracic epidural anesthesia for ventricular tachycardia electrical storm: Ki-Woon Kang; Received November 17, 2021 Accepted March 7, 2022 Published online May 31, 2022; DOI: https://doi.org/10.4266/acc.2021.01683 [Epub ahead of print]

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Abstract PDF: Ventricular tachycardia (VT)/ventricular fibrillation (VF) storm can be hemodynamically compromising and life-threatening. Management of medically refractory VT/VF storm is challenging in the intensive care unit. A 38-year-old male patient was diagnosed with non-ischemic heart failure and acute kidney injury with documented frequent premature ventricular contraction with QT prolongation after recurrent VT/VF. Even though the patient was intubated with sedatives and had taken more than two anti-arrhythmic drugs with external recurrent defibrillation at bedside, the electrical storm persisted for several hours. However, medically refractory VT/VF storm can be successfully and rapidly terminated with a modified thoracic epidural anesthesia at bedside. This case demonstrates that a bedside thoracic epidural anesthesia can be an effective non-pharmacological option to treat medically refractory VT/VF storm in the intensive care unit.

Original Article

Nursing
The effect of time management education on critical care nurses’ prioritization: a randomized clinical trial: Fatemeh Vizeshfar, Mahnaz Rakhshan, Fatemeh Shirazi, Roya Dokoohaki; Acute Crit Care. 2022;37(2):202-208. Published online April 28, 2022; DOI: https://doi.org/10.4266/acc.2021.01123

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Abstract PDF: necessiBackground: Nurses are at the forefront of patient care, and time management skills can increase their ability to make decisions faster. This study aimed to assess the effect of a time management workshop on prioritization and time management skills among nurses of emergency and intensive care units.
Methods
This randomized clinical trial was performed with 215 nurses. The educational intervention about time management was held in the form of a workshop for the intervention group. The time management questionnaire was completed by both groups before, immediately after, and 3 months after the intervention.
Results
Most participants were female (n=191, 88%), with a mean age of 31.82 years (range, 22–63 years). Additionally, the participants’ work experience ranged from 1 to 30 years (mean±standard deviation, 8.00±7.15 years). After the intervention, the mean score of time management increased significantly in the intervention group, but no significant difference was observed in this regard in the control group. The results also revealed a significant difference between the intervention and control groups regarding the mean score of time management 3 months after the intervention (P<0.001).
Conclusions
Time management training helped nurses adjust the time required to perform and prioritize various tasks.

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