Management of Pediatric Septic Shock and Acute Respiratory Distress Syndrome in Thailand: A Survey of Pediatricians

Introduction: Pediatric septic shock and acute respiratory distress syndrome (pARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). While standardized guidelines for sepsis and pARDS are published regularly, their implementation and adherence to guidelines are different in resource-rich and resource-limited countries. The purpose of this study was to conduct a survey to ascertain variation in current clinician-reported practice in pediatric septic shock and acute respiratory distress syndrome, and the clinician skills in a variety of hospital settings throughout Thailand.Methods: We conducted an electronic survey in pediatricians throughout the country between August 2020 and February 2021 using multiple choice questions and clinical case scenarios based on the 2017 American College of Critical Care Medicine's Consensus guideline for pediatric and neonatal septic shock and the 2015 Pediatric Acute Lung Injury Consensus Conference.Results: The survey elicited responses from 255 pediatricians (125 general pediatricians, 38 pulmonologists, 27 cardiologists, 32 intensivists, and 33 other subspecialists), with 54.5% of the respondents having <5 years of PICU experience. Among the six sepsis scenarios, 72.5 and 78.4% of the respondents had good adherence to the guidelines for managing fluid refractory shock and sedation for intubation, respectively. The ICU physicians reported greater adherence during more complex shock. In ARDS scenarios, 80.8% of the respondents reported having difficulty diagnosing ARDS mimic conditions and used lesser PEEP than the recommendation. Acceptance of permissive hypercapnia and mild hypoxemia was accepted by 62.4 and 49.4% of respondents, respectively. The ICU physicians preferred decremental PEEP titration, whereas general pediatricians preferred incremental PEEP titration.Conclusion: This survey variation could be the result of resource constraints, knowledge gaps, or ambiguous guidelines. Understanding the perspective and rationale for variation in pediatricians' practices is critical for successful guideline implementation.

Burnout syndrome among Thai intensivists and nurses in pre-COVID19 era

Background: Burnout syndrome (BOS), a work-related constellation of symptoms and signs, causes individuals emotional stress and is associated with increasing job-related disillusionment. ICU-BOS among Thai intensivists and ICU nurses has never been clarified. Methods & materials: We performed a multicenter, prospective cross-sectional study in 17 hospitals in Thailand. BOS-related data were collected from full time ICU physicians and ICU nurses using electronic questionnaires. ICU-BOS was defined when participants exhibited at least 1 of 3 aspects (depersonalization, emotion exhaustion and personal accomplishment) regarding the Maslach Burnout Inventory. Primary outcome was prevalence of ICU-BOS among intensivists and ICU nurses, and secondary outcomes were risk factors for ICU-BOS. Results: After a total of 193 electronic surveys were sent, 171 responders (ICU physicians n=66, ICU nurses n=105) were included in this analysis (88.6%). Overall prevalence of ICU-BOS was 62.6%. Using multivariate analysis, the risk factors for ICU-BOS among intensivists were 1) income <20,000 THB, 2) feeling of quitting caring for patients in an ICU within the past year, 3) need >2 holidays/wk and 4) patient’s ICU-LOS >5 days (adjusted odd ratio (OR) of 31.5, 15.9, 7.4, 14.9; p =0.04, 0.007, 0.035, 0.004 respectively). Risk factors for ICU-BOS among ICU nurses were 1) age >40 years, 2) ICU experience >5 years, 3) patient’s ICU-LOS >5 days, 4) nurse to patient ratio lower than 1:1 5) feeling assignments in the ICU were too numerous and 6) feeling of quitting caring for patients in an ICU within the past year (adjusted OR of 15.7, 4.6, 10.0, 68.7, 4.3, 5.3; p =0.009, 0.04, 0.004, 0.004, 0.04, 0.007 respectively). Conclusion: In this study, we found a high prevalence of ICU-BOS among Thai intensivists and ICU nurses. Co-independent risk factors for BOS were patient’s ICU-LOS >5 days and feeling of quitting caring for patients in an ICU within the past year.

Advantages of score-based delirium detection compared to a clinical delirium assessment—a retrospective, monocentric cohort study

Purpose Delirium is an underdiagnosed complication on intensive care units (ICU). We hypothesized that a score-based delirium detection using the Nudesc score identifies more patients compared to a traditional diagnosis of delirium by ICU physicians. Methods In this retrospective study, all patients treated on a general medical ICU with 30 beds in a university hospital in 2019 were analyzed. Primary outcome was a documented physician diagnosis of delirium, or a delirium score ≥2 using the Nudesc. Results In 205/943 included patients (21.7%), delirium was diagnosed by ICU physicians compared to 438/943 (46.4%; ratio 2.1) by Nudesc≥2. Both assessments were independent predictors of ICU stay (p<0.01). The physician diagnosis however was no independent predictor of mortality (OR 0.98 (0.57–1.72); p = 0.989), in contrast to the score-based diagnosis (OR 2.31 (1.30–4.10); p = 0.004). Subgroup analysis showed that physicians underdiagnosed delirium in case of hypoactive delirium and delirium in patients with female gender and in patients with an age below 60 years. Conclusion Delirium in patients with hypoactive delirium, female patients and those below 60 years was underdiagnosed by physicians. The score-based delirium diagnosis detected delirium more frequently and correlated with ICU mortality and stay.

Extending the Ring Theory of Personhood to the Care of Dying Patients in Intensive Care Units

It is evident, in the face of the COVID-19 pandemic that has physicians confronting death and dying at unprecedented levels along with growing data suggesting that physicians who care for dying patients face complex emotional, psychological and behavioural effects, that there is a need for their better understanding and the implementation of supportive measures. Taking into account data positing that effects of caring for dying patients may impact a physician’s concept of personhood, or “what makes you, ‘you’”, we adopt Radha Krishna’s Ring Theory of Personhood (RToP) to scrutinise the experiences of physicians working in intensive care units (ICU) using a fictional scenario that was inspired by real events. The impact of death and dying, its catalysts, internal constituents, external factors, dyssynchrony, and buffers, specific to ICU physicians, were identified and explored. Such a framework allows for ramifications to be considered holistically and facilitates the curation of strategies for conflict resolution. This evaluation of the RToP acknowledges the experience and wide-ranging effects it has on ICU physicians. As such, our findings provide insight into their specific needs and highlight the importance of support on a personal and organisational level. Although further research needs to be conducted, the RToP could serve as the basis for a longitudinal assessment tool supported by the use of portfolios or mentorship due to their provision of personalised, appropriate, specific, timely, accessible and long-term support.

Superiority of Supervised Machine Learning on Reading Chest X-Rays in Intensive Care Units

Purpose: Portable chest radiographs are diagnostically indispensable in intensive care units (ICU). This study aimed to determine if the proposed machine learning technique increased in accuracy as the number of radiograph readings increased and if it was accurate in a clinical setting.Methods: Two independent data sets of portable chest radiographs (n = 380, a single Japanese hospital; n = 1,720, The National Institution of Health [NIH] ChestX-ray8 dataset) were analyzed. Each data set was divided training data and study data. Images were classified as atelectasis, pleural effusion, pneumonia, or no emergency. DenseNet-121, as a pre-trained deep convolutional neural network was used and ensemble learning was performed on the best-performing algorithms. Diagnostic accuracy and processing time were compared to those of ICU physicians.Results: In the single Japanese hospital data, the area under the curve (AUC) of diagnostic accuracy was 0.768. The area under the curve (AUC) of diagnostic accuracy significantly improved as the number of radiograph readings increased from 25 to 100% in the NIH data set. The AUC was higher than 0.9 for all categories toward the end of training with a large sample size. The time to complete 53 radiographs by machine learning was 70 times faster than the time taken by ICU physicians (9.66 s vs. 12 min). The diagnostic accuracy was higher by machine learning than by ICU physicians in most categories (atelectasis, AUC 0.744 vs. 0.555, P &lt; 0.05; pleural effusion, 0.856 vs. 0.706, P &lt; 0.01; pneumonia, 0.720 vs. 0.744, P = 0.88; no emergency, 0.751 vs. 0.698, P = 0.47).Conclusions: We developed an automatic detection system for portable chest radiographs in ICU setting; its performance was superior and quite faster than ICU physicians.

Assessment of the Quality of Chest Compressions Performed by Health-Care Workers Under Simulated Conditions

Aim of the study: to investigate chest compression parameters by city hospital staff under simulated conditions with and without the use of a sensor device for quality control of chest compressions.Materials and Methods. The study was conducted in Moscow's multidisciplinary hospitals. The study included 359 medical staff members. The participants were divided into 4 groups: physicians (n=97) and nurses (n=82) from intensive care units (ICU) and physicians (n=92) and nurses (n=88) from specialized departments. Participants performed 2 minutes of chest compressions without a chest compressions quality control (CCQC) sensor, followed by 2 minutes of chest compressions using a defibrillator sensor with audiovisual prompts from the device turned on. The percentage of target compressions, rate and depth of compressions were analyzed.Results. Compression parameters in the group of ICU doctors were outside the reference range (% target compression — 0.5 (0.0; 14.5)%, rate 124.1±17.8 per minute, depth 5.6±1.1 cm), in the group of ICU nurses, the percentage of target compressions was 0.0 (0.0; 3.5)%, rate — 123.6±23.7 per minute, depth — 5.3±1.2 cm, in the group of specialist doctors the percentage of target compressions was 0.0 (0.0; 1.2) %, rate — 123.8±23.2 per minute, depth — 5.8±1.2 cm, in specialized nurses group the percentage of target compressions was 0.0 (0.0; 6.1)%, rate — 119.7±29.5 per minute, depth — 5.6±1.2 cm. There was a significant improvement in compression performance in all groups when the sensor device was used: in ICU physicians the percentage of target compressions was 81.6 (64.80; 87.90)%, rate — 124.1±17.8 per minute, depth — 5.5±0.2 cm; in ICU nurses the percentage of target compressions was 69.1 (47.4; 80.6), rate — 123.6±23.7 per minute, depth — 5.3±0.3 cm, in specialist doctors the percentage of target compressions was 69.30 (50.50; 78.70), rate — 123.8±23.2 per minute, depth — 5.4±0.3 cm, in specialized nurses the percentage of target compressions reached 63.70 (42.90; 75.80), rate — 119.7±29.5 per minute, depth — 5.4±0.3 cm. There were no differences in analysed compression parameters between staff in different departments or positions.Conclusion. Compression parameters (percentage of target compressions, rate, depth) were not influenced by the department where the staff member worked and the position held (doctor or nurse). The use of a compression quality sensor device has improved compression parameters by reducing rate and normalizing depth. The use of the sensor does not increase the percentage of target compressions to the maximum values, indicating the need for training by an instructor.

Case fatality inequalities of critically ill COVID-19 patients according to patient-, hospital- and region-related factors: a French nationwide study

Background The COVID-19 sanitary crisis inflicted different challenges regarding the reorganization of the human and logistic resources, particularly in intensive care unit (ICU). Interdependence between regional pandemic burden and individual outcome remains unknown. The study aimed to assess the association between ICU bed occupancy and case fatality rate of critically ill COVID-19 patients. Methods A cross-sectional study was performed in France, using the national hospital discharge database from March to May, 2020. All patients admitted to ICU for COVID-19 were included. Case fatality was described according to: (i) patient’s characteristics (age, sex, comorbid conditions, ICU interventions); (ii) hospital’s characteristics (baseline ICU experience assessed by the number of ICU stays in 2019, number of ICU physicians per bed), and (iii) the regional outbreak-related profiles (workload indicator based on ICU bed occupancy). The determinants of lethal outcome were identified using a logistic regression model. Results 14,513 COVID-19 patients were admitted to ICU; 4256 died (29.3%), with important regional inequalities in case fatality (from 17.6 to 33.5%). Older age, multimorbidity and clinical severity were associated with higher mortality, as well as a lower baseline ICU experience of the health structure. Regions with more than 10 days with ≥ 75% of ICU occupancy by COVID-19 patients experienced an excess of mortality (up to adjusted OR = 2.2 [1.9–2.6] for region with the highest occupancy rate of ICU beds). Conclusions The regions with the highest burden of care in ICU were associated with up to 2.2-fold increase of death rate.

Shared decision-making in the ICU from the perspective of physicians, nurses and patients: a qualitative interview study

ObjectiveTo identify views, experiences and needs for shared decision-making (SDM) in the intensive care unit (ICU) according to ICU physicians, ICU nurses and former ICU patients and their close family members.DesignQualitative study.SettingTwo Dutch tertiary centres.Participants19 interviews were held with 29 participants: seven with ICU physicians from two tertiary centres, five with ICU nurses from one tertiary centre and nine with former ICU patients, of whom seven brought one or two of their close family members who had been involved in the ICU stay.ResultsThree themes, encompassing a total of 16 categories, were identified pertaining to struggles of ICU physicians, needs of former ICU patients and their family members and the preferred role of ICU nurses. The main struggles ICU physicians encountered with SDM include uncertainty about long-term health outcomes, time constraints, feeling pressure because of having final responsibility and a fear of losing control. Former patients and family members mainly expressed aspects they missed, such as not feeling included in ICU treatment decisions and a lack of information about long-term outcomes and recovery. ICU nurses reported mainly opportunities to strengthen their role in incorporating non-medical information in the ICU decision-making process and as liaison between physicians and patients and family.ConclusionsInterviewed stakeholders reported struggles, needs and an elucidation of their current and preferred role in the SDM process in the ICU. This study signals an essential need for more long-term outcome information, a more informal inclusion of patients and their family members in decision-making processes and a more substantial role for ICU nurses to integrate patients’ values and needs in the decision-making process.

Chinese ICU Physicians’ Knowledge of Antibiotic Pharmacokinetics/Pharmacodynamics (PK/PD): A Cross-Sectional Survey

Background: Patients with sepsis have a high mortality rate, accumulated evidences suggest that an optimal antibiotic administration strategy based on pharmacokinetics/pharmacodynamics（PK/PD）can improve the prognosis of septic patients. Therefore, we assessed Chinese intensive care unit (ICU) physicians’ knowledge about PK/PD.Methods: In December 2019, we designed a questionnaire focused on Chinese ICU physicians’ knowledge about PK/PD and collected the questionnaires after 3 months. The questionnaire was distributed via e-mail and WeChat, and was distributed to ICU doctors in 31 administrative regions of China except Hong Kong, Macao and Taiwan. The passing score was corrected by the Angoff method, and the ICU physicians’ knowledge about PK/PD was analysed accordingly.Results: We received a total of 1,309 questionnaires and retained 1,240 valid questionnaires. The passing score was 90.8, and the overall pass rate was 56.94%. The pass rate for tertiary and secondary hospitals was 59.07% and 37.19%, respectively. ICU physicians with less than 5 years of work experience and resident physician accounted for the highest pass rate, while those with between 5 to 10 years of work experience and attending accounted for the lowest pass rate. The majority of participants in the Chinese Critical Care Certified Course (5C) were from Jiangsu and Henan provinces, and they had the highest average scores (125.8 and 126.5, respectively). For Beijing and Shanghai, the average score was only 79.4 and 90.9, respectively.Conclusions: Chinese ICU physicians’ knowledge about PK/PD is unsatisfactory. Therefore, it is essential to strengthen ICU physicians’ knowledge about PK/PD.

Non-readmission decisions in the intensive care unit: A qualitative study of physicians’ experience in a multicentre French study

Purpose Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians regarding non-readmission of patients to the ICU. Materials and methods Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis. Results In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient’s care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous. Conclusions Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient’s goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement.