Annachiara Marra

The ABCDEF Bundle in Critical Care

The ABCDEF bundle represents an evidence-based guide for clinicians to approach the organizational changes needed for optimizing intensive care unit patient recovery and outcomes. This article reviews the core evidence and features behind the ABCDEF bundle. The bundle has individual components that are clearly defined, flexible to implement, and help empower multidisciplinary clinicians and families in the shared care of the critically ill. The ABCDEF bundle helps guide well-rounded patient care and optimal resource utilization resulting in more interactive intensive care unit patients with better controlled pain, who can safely participate in higher-order physical and cognitive activities at the earliest point in their critical illness.

Intensive Care Unit Delirium and Intensive Care Unit–Related Posttraumatic Stress Disorder

Delirium is one of the most common behavioral manifestations of acute brain dysfunction in the intensive care unit (ICU) and is a strong predictor of worse outcome. Routine monitoring for delirium is recommended for all ICU patients using validated tools. In delirious patients, a search for all reversible precipitants is the first line of action and pharmacologic treatment should be considered when all causes have been ruled out, and it is not contraindicated. Long-term morbidity has significant consequences for survivors of critical illness and for their caregivers. ICU patients may develop posttraumatic stress disorder related to their critical illness experience.

Performances of CPAP Devices With an Oronasal Mask

BACKGROUND: The aim of this bench study was to investigate the performances of 8 devices for noninvasive CPAP. METHODS: Eight devices for noninvasive CPAP with an orofacial mask were studied: Ventumask, Ventumask 30, EasyVent, EasyVent Emergency, Compact Model II, Flowone, Superflow, Boussignac CPAP valve. Each device was tested at oxygen input flows from 5 to 20 L/min, and the output gas flow was measured in static conditions. Each device was evaluated during a eupneic and a tachypneic simulated breathing test. RESULTS: The gas output flow generated by each device increased with higher oxygen input flow; EasyVent and Flowone produced the highest output flow (P < .001). At the simulated eupneic breathing test, Superflow and EasyVent showed a more stable pressure swing at different PEEP levels, whereas the other masks had a greater swing, between 10 and 15 cm H2O PEEP (P = .002 for all pairwise comparisons). During the tachypneic breathing test, the pressure swing was stable with Flowone and EasyVent (P = .055), whereas it had increased with other masks (P = .002 for all pairwise comparisons). CONCLUSIONS: We found a significant variation in the performances of the 8 CPAP devices examined in this study. The technical characteristics and limitations of different CPAP devices should be considered when using in patients with hypoxemic acute respiratory failure.

Focusing on Inattention: The Diagnostic Accuracy of Brief Measures of Inattention for Detecting Delirium

BACKGROUND Delirium is frequently missed in most clinical settings. Brief delirium assessments are needed. OBJECTIVE To determine the diagnostic accuracy of reciting the months of year backwards (MOTYB) from December to July (MOTYB-6) and December to January (MOTYB-12) for delirium as diagnosed by a psychiatrist and to explore the diagnostic accuracies of the following other brief attention tasks: (1) spell the word “LUNCH” backwards, (2) recite the days of the week backwards, (3) 10-letter vigilance “A” task, and (4) 5 picture recognition task. DESIGN Preplanned secondary analysis of a prospective observational study. SETTING Emergency department located within an academic, tertiary care hospital. PARTICIPANTS 234 acutely ill patients who were ≥65 years old. MEASUREMENTS The inattention tasks were administered by a physician. The reference standard for delirium was a comprehensive psychiatrist assessment using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria. Sensitivities and specificities were calculated. RESULTS Making any error on the MOTYB-6 task had a sensitivity of 80.0% (95% confidence interval [CI], 60.9%-91.1%) and specificity of 57.1% (95% CI, 50.4%-63.7%). Making any error on the MOTYB-12 task had a sensitivity of 84.0% (95% CI, 65.4%-93.6%) and specificity of 51.9% (95% CI, 45.2%-58.5%). The best combination of sensitivity and specificity was reciting the days of the week backwards task; if the patient made any error, this was 84.0% (95% CI, 65.4%-93.6%) sensitive and 81.9% (95% CI, 76.1%-86.5%) specific. CONCLUSION MOTYB-6 and MOTYB-12 had very good sensitivities but had modest specificities for delirium, limiting their use as a standalone assessment. Reciting the days of the week backwards appeared to have the best combination of sensitivity and specificity for delirium.

Acute Brain Dysfunction: Development and Validation of a Daily Prediction Model

Background The goal of this study was to develop and validate a dynamic risk model to predict daily changes in acute brain dysfunction (ie, delirium and coma), discharge, and mortality in ICU patients. Methods Using data from a multicenter prospective ICU cohort, a daily acute brain dysfunction‐prediction model (ABD‐pm) was developed by using multinomial logistic regression that estimated 15 transition probabilities (from one of three brain function states [normal, delirious, or comatose] to one of five possible outcomes [normal, delirious, comatose, ICU discharge, or died]) using baseline and daily risk factors. Model discrimination was assessed by using predictive characteristics such as negative predictive value (NPV). Calibration was assessed by plotting empirical vs model‐estimated probabilities. Internal validation was performed by using a bootstrap procedure. Results Data were analyzed from 810 patients (6,711 daily transitions). The ABD‐pm included individual risk factors: mental status, age, preexisting cognitive impairment, baseline and daily severity of illness, and daily administration of sedatives. The model yielded very high NPVs for “next day” delirium (NPV: 0.823), coma (NPV: 0.892), normal cognitive state (NPV: 0.875), ICU discharge (NPV: 0.905), and mortality (NPV: 0.981). The model demonstrated outstanding calibration when predicting the total number of patients expected to be in any given state across predicted risk. Conclusions We developed and internally validated a dynamic risk model that predicts the daily risk for one of three cognitive states, ICU discharge, or mortality. The ABD‐pm may be useful for predicting the proportion of patients for each outcome state across entire ICU populations to guide quality, safety, and care delivery activities.

Tracheostomy in Intensive Care Unit: The Need of European Guidelines

Surgical or percutaneous tracheostomies have become one of the most frequently performed procedures in intensive care unit. Over the past years, different percutaneous tracheostomy techniques have been proposed. Surveys conducted in different European Countries showed that tracheostomy techniques, procedural features as well as complications are markedly heterogeneous among European ICUs and might differ even within ICUs from one country to another. Lacking clinical guidelines to provide the best available scientific evidence and to reduce inappropriate variation in PT practice, a careful analysis of different surveys suggested to physicians the most common practice associated with PT.

Complications of Percutaneous and Surgical Tracheostomy in Critically Ill Patients

Percutaneous tracheostomy is more widely used in intensive care unit. In critical patients, it has many potential advantages over endotracheal intubation including reduction of respiratory resistance, work of breathing, length of mechanical ventilation, laryngeal injury and a better clearance of airway secretions. From a practical point of view, percutaneous tracheostomy is a safe and cost-effective technique performed at bedside, but it is not without risks and complications. The reported incidence of significant complications for PDT is about 1–10 %, including both short-term and long-term complications.

Clinical Practice of Informed Consent for Percutaneous Tracheostomy

Informed consent (IC) is the process through which patients understand and agree to medical procedures. The informed consent process needs to fulfil two main purposes: (1) the moral and ethical right of autonomy and freedom of choice and (2) the legal authorisation for the proposed treatment. The IC is not simply a legal and ethical obligation; it is central factor in decisional process helping the patient arrive at a treatment decision. The competence is the most important element to obtain a valid informed consent. The majority of critically ill patients are naturally incompetent and not legally incompetent. This kind of patients has a temporarily or partially mental incapacity that requires a surrogate decision maker. The purpose of this chapter is to report the problems of IC in critically ill patients and to show the different national legislation about it.