Julie Benbenishty

Hydrocortisone therapy for patients with septic shock.

BACKGROUND Hydrocortisone is widely used in patients with septic shock even though a survival benefit has been reported only in patients who remained hypotensive after fluid and vasopressor resuscitation and whose plasma cortisol levels did not rise appropriately after the administration of corticotropin. METHODS In this multicenter, randomized, double-blind, placebo-controlled trial, we assigned 251 patients to receive 50 mg of intravenous hydrocortisone and 248 patients to receive placebo every 6 hours for 5 days; the dose was then tapered during a 6-day period. At 28 days, the primary outcome was death among patients who did not have a response to a corticotropin test. RESULTS Of the 499 patients in the study, 233 (46.7%) did not have a response to corticotropin (125 in the hydrocortisone group and 108 in the placebo group). At 28 days, there was no significant difference in mortality between patients in the two study groups who did not have a response to corticotropin (39.2% in the hydrocortisone group and 36.1% in the placebo group, P=0.69) or between those who had a response to corticotropin (28.8% in the hydrocortisone group and 28.7% in the placebo group, P=1.00). At 28 days, 86 of 251 patients in the hydrocortisone group (34.3%) and 78 of 248 patients in the placebo group (31.5%) had died (P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. However, there were more episodes of superinfection, including new sepsis and septic shock. CONCLUSIONS Hydrocortisone did not improve survival or reversal of shock in patients with septic shock, either overall or in patients who did not have a response to corticotropin, although hydrocortisone hastened reversal of shock in patients in whom shock was reversed. (ClinicalTrials.gov number, NCT00147004.)

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Determinants of Procedural Pain Intensity in the Intensive Care Unit. The Europain® Study

RATIONALE Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known. OBJECTIVES To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity. METHODS Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries. MEASUREMENTS AND MAIN RESULTS Pain intensity on a 0-10 numeric rating scale increased significantly from baseline pain during all procedures (P < 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3-7), 4.5 (2-7), and 4 (2-6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately. CONCLUSIONS Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082).

Nurse involvement in end-of-life decision making: the ETHICUS Study

ObjectiveThe purpose was to investigate physicians’ perceptions of the role of European intensive care nurses in end-of-life decision making.DesignThis study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.SettingThe study took place in 37 intensive care units in 17 European countries.Patients and participantsPhysician investigators reported data related to patients from 37 centers in 17 European countries.InterventionsNone.Measurements and resultsPhysicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.ConclusionsPhysicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study

PurposeThis study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings).MethodsIn 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews.ResultsA total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient’s refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient’s autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients’ wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients’ wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones.ConclusionsHealth-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

Characteristics of patients receiving vasopressors

BACKGROUND Patients receiving intensive care frequently need pharmacologic support of their blood pressure because of shock. In some patients, shock is so severe that extremely high doses of vasopressors are needed to elevate their blood pressure. OBJECTIVE We sought to ascertain the maximal dose of vasopressors administered to patients, and to describe the population of patients receiving vasopressors in one intensive care unit. METHODS All adult patients admitted in 2001 to a 10-bed surgical unit in a university hospital, and receiving a vasopressor agent for 1 hour or more, underwent recordings of their demographic data, diagnoses upon admission, Acute Physiological and Chronic Health Evaluation (APACHE) II scores, vasopressors (including type, initial dose, dose increases, and maximal dose), number of days administered, complications, and mortality. RESULTS Of 689 patients whose charts were reviewed, 72 received vasopressors. The mean age was 65 ± 21.4 years, and 66% were male. The mean APACHE II scores were 24 ± 6.2. The administration of .5 μg/kg/minute of norepinephrine or epinephrine resulted in 96% sensitivity and a specificity of 76% for the likelihood of mortality. Using Kaplan-Meyer curves, those patients receiving less than .5 μg/kg/minute demonstrated an 80% 6-year survival. All 17 patients receiving more than 3.8 μg/kg/minute of norepinephrine, and all 5 patients receiving more than 9.6 μg/kg/minute of epinephrine, died. The length of time during which patients received less than their maximal dose of vasopressors had no influence on survival (P = .4). The elderly (aged ≥ 75 years) and the young (aged <75 years) had the same intensive care unit survival rates when receiving vasopressors. CONCLUSION In this study, little likelihood of intensive care unit survival was evident when patients received more than .5 μg/kg/minute of norepinephrine or epinephrine.

Understanding nurse–physician conflicts in the ICU

Received: 17 September 2014 Accepted: 8 October 2014 Published online: 18 October 2014 Springer-Verlag Berlin Heidelberg and ESICM 2014 C. S. Hartog ()) Department for Anesthesiology and Intensive Care, Jena University Hospital, Erlanger Allee 101, 07743 Jena, Germany e-mail: Christiane.hartog@med.uni-jena.de Tel.: ?49 3641 9323171 C. S. Hartog Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany

Preparing research instruments for use with different cultures

There is a growing requirement to use standardised instruments for collecting research data and monitoring patient progress. Two sets of properties should be addressed when selecting and adapting research instruments: psychometric properties (validity, appropriateness, reliability, and responsiveness) and clinical properties (feasibility and acceptability of the instrument). This paper outlines steps necessary to fulfil these requirements when using a research instrument in different cultures.

Translation of Oral Care Practice Guidelines Into Clinical Practice by Intensive Care Unit Nurses

PURPOSE The purpose of this study was to determine whether there was a change in the oral care practices of intensive care unit (ICU) nurses for ventilated patients after a national effort to increase evidence-based oral care practices. DESIGN Descriptive comparison of ICU nurses in 2004-2005 and 2012. METHOD Two convenience national surveys of ICU nurses were collected in 2004-2005 (n = 218) and 2012 (n = 233). After the results of the initial survey were reported, a national effort to increase awareness of evidence-based oral care practices was conducted that included in-service presentations; publication of an evidence-based protocol in a national nursing journal; publication of the survey findings in an international nursing journal; and reports to the local press. A repeat survey was conducted 7 to 8 years later. The same survey instrument was used for both periods of data collection. This questionnaire included questions about demographic and personal characteristics and a checklist of oral care practices. Nurses rated their perceived priority level concerning oral care on a scale from 0 to 100. An evidence-based practice (EBP)[O4] score was computed representing the sum of 14 items related to equipment, solutions, assessments, and techniques associated with the evidence. The EBP score, priority score, and oral care practices were compared between the two samples. A regression model was built based on those variables that were associated with the EBP score in 2012. FINDINGS There was a statistically significant increase in the use of EBPs as shown by the EBP score and in the perceived priority level of oral care. Increased EBPs were found in the areas of teeth brushing and oral assessment. Decreases were found in the use of non-evidence-based practices, such as the use of gauze pads, tongue depressors, lemon water, and sodium bicarbonate. No differences were found in the use of chlorhexidine, toothpaste, or the nursing documentation of oral care practices. A multiple regression model was found to be significant with the time of participation (2004-2005 vs. 2012) and priority level of oral care significantly contributing to the regression model. CONCLUSIONS The national effort was partially successful in improving evidence-based oral care practices; however, increased awareness to EBP also might have come from other sources. Other strategies related to knowledge translation need to be attempted and researched in this clinical setting such as the use of opinion leaders, audits and feedback, small group consensus, provider reminder systems, incentives, clinical information systems, and computer decision support systems. CLINICAL RELEVANCE This national effort to improve EBP did reap some rewards; however, other knowledge translation strategies should be used to further improve clinical practice.

Systematic Review of Gender- dependent outcomes in sepsis

BACKGROUND Men and women appear to exhibit different susceptibilities to sepsis and possibly divergent outcomes. However, the effect of sex and gender in critical illness outcomes is still controversial and the underlying mechanisms appear to be complex. OBJECTIVES We aimed to systematically review and synthesize evidence on the influence of sex on outcomes in critically ill adult patients with sepsis, as reported in published studies specifically including investigation of the effect of sex among their aims. Primary outcome measures include in-hospital mortality, intensive care unit (ICU) mortality and length of stay (LOS) in the ICU. SEARCH STRATEGY The review was based on focused literature searches (CINAHL, PUBMED, EMBASE and COCHRANE). Methodological quality was assessed through the STROBE checklist and the Cochrane Tool for Bias in Cohort Studies. Meta-analysis was performed using STATA. Published observational studies addressing outcomes of sepsis among their primary aims and having included gender comparisons among primary outcomes in critically ill adult patients were included. RESULTS A total of eight eligible studies were included. With the exception of mortality, it was not possible to perform meta-analysis for other outcomes. Included studies reported data on 25,619 patients with sepsis (14 309 male/11 310 female). There is a paucity of well-designed studies addressing the effect of sex on mortality among patients with sepsis, and absence of studies addressing the effects of sex on multiple organ dysfunction of non-infectious origin. There was significant heterogeneity among study estimates (p = 0·001; I2 =78·1%). CONCLUSIONS Although results of data syntheses appear to point towards a small disadvantage for survival among women, our results suggest that data on the impact of sex on sepsis outcomes remain equivocal. Implications for future research include approaches to adjustment for confounders and prospective designs. RELEVANCE TO CLINICAL PRACTICE Clarifying sex-related differences in sepsis, if any, is crucial for informing evidence-based care.