The Effect of Rapid Initiation Versus Delayed Initiation of Antibiotics in Pediatric Patients With Sepsis

OBJECTIVE The purpose of this study was to determine if administration of antibiotics within 1 hour of meeting sepsis criteria improved patient outcomes versus antibiotics administered greater than 1 hour after meeting sepsis criteria in pediatric patients. The Surviving Sepsis Campaign's international guidelines recommend appropriate antimicrobial therapy be administered within 1 hour of recognition of severe sepsis or septic shock. Data regarding outcomes in pediatric patients with sepsis regarding antibiotic timing are currently limited. METHODS This was a retrospective chart review of 69 pediatric patients admitted between July 1, 2013, and June 30, 2016, with a diagnosis of sepsis. RESULTS The primary outcome of in-hospital mortality was 7.1% in the within 1 hour group versus 14.6% in the greater than 1 hour group (p = 0.3399). Median hospital length of stay was significantly shorter in the within 1 hour group (15.4 versus 39.2 days, p = 0.0022). Median intensive care unit length of stay was also significantly shorter in the within 1 hour group (3.1 versus 33.6 days, p = 0.0191). There were no differences between groups for pediatric intensive care unit admission, end organ dysfunction, time to intubation, or time on the ventilator. CONCLUSIONS Pediatric patients who receive antimicrobial therapy within 1 hour of meeting sepsis criteria had improved hospital and intensive care unit length of stay. This study supports the Surviving Sepsis Guidelines recommendation to administer antibiotics within 1 hour in pediatric patients with sepsis or septic shock.

Favorable Outcomes After Implementing a Nurse-Driven Sedation Protocol

Background In patients receiving mechanical ventilation, prolonged exposure to sedative and analgesic medications contributes to negative clinical outcomes. Objective To reduce exposure to sedative and analgesic medications among patients receiving mechanical ventilation by implementing a nurse-driven sedation protocol. Methods This quality improvement project followed a plan-do-study-act cycle. Nurses were educated on the protocol, and 30 patient medical records were reviewed both before and after protocol implementation. Data were extracted on intensive care unit length of stay, duration of mechanical ventilation, duration of continuous sedation, presence of delirium, pain, level of sedation, and performance and documentation of spontaneous awakening trials. Data were analyzed using descriptive statistics, the χ2 test, and calculated percent change. Results Forty-four nurses completed protocol education. The mean (SD) duration of mechanical ventilation decreased by 26% (from 5 [3.7] days to 3.7 [3.2] days), and the mean (SD) intensive care unit length of stay decreased by 27% (from 6.3 [4.3] days to 4.6 [3.7] days). The mean (SD) duration of continuous sedation decreased by 35% (from 6419 [7241] minutes to 4178 [4507] minutes). Spontaneous awakening trials documented increased by 35% (from 57% to 77%), and spontaneous awakening trials performed increased by 92% (from 40% to 77%), a statistically significant change (P = .004). Conclusion These preliminary data suggest that implementation of a nurse-driven sedation protocol resulted in favorable outcomes by decreasing duration of mechanical ventilation, intensive care unit length of stay, and duration of continuous sedation and increasing the number of spontaneous awakening trials performed.

Effect of intrapulmonary percussive ventilation on intensive care unit length of stay, the incidence of pneumonia and gas exchange in critically ill patients: A systematic review

Background Pulmonary complications such as pneumonia, pulmonary atelectasis, and subsequent respiratory failure leading to ventilatory support are a common occurrence in critically ill patients. Intrapulmonary percussive ventilation (IPV) is used to improve gas exchange and promote airway clearance in these patients. The current evidence regarding the effectiveness of intrapulmonary percussive ventilation in critical care settings remains unclear. This systematic review aims to summarise the evidence of the effectiveness of intrapulmonary percussive ventilation on intensive care unit length of stay (ICU-LOS) and respiratory outcomes in critically ill patients. Research question In critically ill patients, is intrapulmonary percussive ventilation effective in improving respiratory outcomes and reducing intensive care unit length of stay. Methods A systematic search of intrapulmonary percussive ventilation in intensive care unit (ICU) was performed on five databases from 1979 to 2021. Studies were considered for inclusion if they evaluated the effectiveness of IPV in patients aged ≥16 years receiving invasive or non-invasive ventilation or breathing spontaneously in critical care or high dependency units. Study titles and abstracts were screened, followed by data extraction by a full-text review. Due to a small number of studies and observed heterogeneities in the study methodology and patient population, a meta-analysis could not be included in this review. Outcomes of interest were summarised narratively. Results Out of 306 identified abstracts, seven studies (630 patients) met the eligibility criteria. Results of the included studies provide weak evidence to support the effectiveness of intrapulmonary percussive ventilation in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate. Interpretation Based on the findings of this review, the evidence to support the role of IPV in reducing ICU-LOS, improving gas exchange, and reducing respiratory rate is weak. The therapeutic value of IPV in airway clearance, preventing pneumonia, and treating pulmonary atelectasis requires further investigation.

High flow nasal oxygen in patients with COVID-19 associated acute respiratory failure

Purpose Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high flow nasal oxygen on ventilator free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. Methods We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units. Main exposure was the use of high flow nasal oxygen (conservative group), while early invasive mechanical (within the first day of critical care admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. Intensive care unit length of stay and all-cause in hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. Results A total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days), and a reduction in intensive care unit length of stay (mean difference: -8.2 days; 95% CI -12.7 to -3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). Conclusions The use of high flow nasal oxygen upon intensive care admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in intensive care unit length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.

Derivation and Validation of a Clinical Model to Predict Intensive Care Unit Length of Stay After Cardiac Surgery

Background Across the globe, elective surgeries have been postponed to limit infectious exposure and preserve hospital capacity for coronavirus disease 2019 (COVID‐19). However, the ramp down in cardiac surgery volumes may result in unintended harm to patients who are at high risk of mortality if their conditions are left untreated. To help optimize triage decisions, we derived and ambispectively validated a clinical score to predict intensive care unit length of stay after cardiac surgery. Methods and Results Following ethics approval, we derived and performed multicenter valida tion of clinical models to predict the likelihood of short (≤2 days) and prolonged intensive care unit length of stay (≥7 days) in patients aged ≥18 years, who underwent coronary artery bypass grafting and/or aortic, mitral, and tricuspid value surgery in Ontario, Canada. Multivariable logistic regression with backward variable selection was used, along with clinical judgment, in the modeling process. For the model that predicted short intensive care unit stay, the c‐statistic was 0.78 in the derivation cohort and 0.71 in the validation cohort. For the model that predicted prolonged stay, c‐statistic was 0.85 in the derivation and 0.78 in the validation cohort. The models, together termed the CardiOttawa LOS Score , demonstrated a high degree of accuracy during prospective testing. Conclusions Clinical judgment alone has been shown to be inaccurate in predicting postoperative intensive care unit length of stay. The CardiOttawa LOS Score performed well in prospective validation and will complement the clinician's gestalt in making more efficient resource allocation during the COVID‐19 period and beyond.