Feasibility of a standardized family participation programme in the intensive care unit: A pilot survey study.

AIM: To assess the feasibility and applicability of a standardized programme to facilitate family participation in essential care activities in the intensive care unit. DESIGN: Pilot study with a cross-sectional survey design. METHODS: A standardized programme to facilitate family participation in essential nursing care activities was implemented in intensive care units of three hospitals in the Netherlands from November 2018 until March 2019. The feasibility and applicability of the programme were assessed with surveys of the patients, relatives and healthcare providers. RESULTS: Three intensive care units successfully implemented the standardized programme. Three patients, ten relatives and 37 healthcare providers responded to the surveys. Patients appreciated family participation and recognized that their relatives liked to participate. Relatives appreciated being able to do something for the patient (80%) and to participate in essential care activities (60%). The majority of relatives (60%) felt they had sufficient knowledge and skills to participate and did not feel obliged nor uncomfortable. Healthcare providers felt they were trained adequately and motivated to apply family participation; application was perceived as easy, clear and relatively effortless according to the majority. According to 68% of the healthcare providers, most relatives were perceived to be capable of learning to participate in essential care activities. Some healthcare providers felt uncertain about the patient's wishes regarding family participation, with some indicating the behaviours of relatives and patients discouraged them from offering family participation. Use of a standardized programme to facilitate family participation in essential care activities in the intensive care unit seems feasible and applicable as determined by relatives and healthcare providers.

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality.

INTRODUCTION: Despite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS). METHODS: We performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014-December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used. RESULTS: After applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001). CONCLUSION: Our findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes.

The Impact of Nursing Delirium Preventive Interventions in the ICU: A Multicenter Cluster-randomized Controlled Clinical Trial.

Rationale: Delirium is common in critically ill patients and is associated with deleterious outcomes. Nonpharmacological interventions are recommended in current delirium guidelines, but their effects have not been unequivocally established. Objectives: To determine the effects of a multicomponent nursing intervention program on delirium in the ICU. Methods: A stepped-wedge cluster-randomized controlled trial was conducted in ICUs of 10 centers. Adult critically ill surgical, medical, or trauma patients at high risk of developing delirium were included. A multicomponent nursing intervention program focusing on modifiable risk factors was implemented as standard of care. The primary outcome was the number of delirium-free and coma-free days alive in 28 days after ICU admission. Measurements and Main Results: A total of 1,749 patients were included. Time spent on interventions per 8-hour shift was median (interquartile range) 38 (14-116) minutes in the intervention period and median 32 (13-73) minutes in the control period (P = 0.44). Patients in the intervention period had a median of 23 (4-27) delirium-free and coma-free days alive compared with a median of 23 (5-27) days for patients in the control group (mean difference, -1.21 days; 95% confidence interval, -2.84 to 0.42 d; P = 0.15). In addition, the number of delirium days was similar: median 2 (1-4) days (ratio of medians, 0.90; 95% confidence interval, 0.75 to 1.09; P = 0.27). Conclusions: In this large randomized controlled trial in adult ICU patients, a limited increase in the use of nursing interventions was achieved, and no change in the number of delirium-free and coma-free days alive in 28 days could be determined. Clinical trial registered with www.clinicaltrials.gov (NCT03002701).

Noise in the intensive care unit and its influence on sleep quality: a multicenter observational study in Dutch intensive care units.

BACKGROUND: High noise levels in the intensive care unit (ICU) are a well-known problem. Little is known about the effect of noise on sleep quality in ICU patients. The study aim is to determine the effect of noise on subjective sleep quality. METHODS: This was a multicenter observational study in six Dutch ICUs. Noise recording equipment was installed in 2-4 rooms per ICU. Adult patients were eligible for the study 48 h after ICU admission and were followed up to maximum of five nights in the ICU. Exclusion criteria were presence of delirium and/or inability to be assessed for sleep quality. Sleep was evaluated using the Richards Campbell Sleep Questionnaire (range 0-100 mm). Noise recordings were used for analysis of various auditory parameters, including the number and duration of restorative periods. Hierarchical mixed model regression analysis was used to determine associations between noise and sleep. RESULTS: In total, 64 patients (68% male), mean age 63.9 (± 11.7) years and mean Acute Physiology And Chronic Health Evaluation (APACHE) II score 21.1 (± 7.1) were included. Average sleep quality score was 56 ± 24 mm. The mean of the 24-h average sound pressure levels (LAeq, 24h) was 54.0 dBA (± 2.4). Mixed-effects regression analyses showed that background noise (ß = - 0.51, p < 0.05) had a negative impact on sleep quality, whereas number of restorative periods (ß = 0.53, p < 0.01) and female sex (ß = 1.25, p < 0.01) were weakly but significantly correlated with sleep. CONCLUSIONS: Noise levels are negatively associated and restorative periods and female gender are positively associated with subjective sleep quality in ICU patients. TRIAL REGISTRATION: www.ClinicalTrials.gov, NCT01826799 . Registered on 9 April 2013.

Phlebitis as a consequence of peripheral intravenous administration of cisatracurium besylate in critically ill patients.

This case report series describes 3 cases of cisatracurium besylate associated phlebitis after an infusion period of 14-20 hours. No similar cases have been reported in the literature. Association of phlebitis with another neuromuscular blocking agent, atracurium, has been described in the literature. The acidity of atracurium is thought to be the main cause. It is recommended that atracurium is administered only via central venous catheters when indicated to infuse over prolonged periods of time due to the acidity. Cisatracurium is a stereoisomer of atracurium and as such has the same molecular weight. Although cisatracurium also has a similar acidity as atracurium, a recommendation concerning infusion via a central venous catheter is lacking. We suggest prolonged administration of cisatracurium besylate only via centrally placed venous catheters or if not possible to careful monitor relevant peripheral intravenous sites to diminish the risks of phlebitis and associated complications or other cutaneous reactions.

[Acute liver failure in a young adult]. / Acuut leverfalen bij een jonge patiënte.

Acute liver failure is a rare but mostly severe disorder in previously healthy patients. Viral infections and drugs are the most common causes in the Western world. A small percentage of acute liver failure is caused by Wilson's disease. We describe a previously healthy 23-year-old female with acute haemolytic anemia and liver failure as the first manifestations of Wilson's disease. There was rapid deterioration to multi-organ failure and the patient died less than 24 hours after initial presentation. Relatively simple laboratory tests can be used for initial screening of acute liver failure due to Wilson's disease. Liver transplantation is the only way to ensure survival of the patient. Rapid transfer to a specialised centre is, therefore, of the utmost concern.

The association of the dopamine transporter gene and the dopamine receptor 2 gene with delirium, a meta-analysis.

Delirium is the most common neuropsychiatric syndrome in elderly ill patients. Previously, associations between delirium and the dopamine transporter gene (solute carrier family 6, member 3 (SLC6A3)) and dopamine receptor 2 gene (DRD2) were found. The aim of this study was to validate whether markers of the SLC6A3 and DRD2 genes are were associated with delirium in independent populations. Six European populations collected DNA of older delirious patients. Associations were determined per population and results were combined in a meta-analysis. In total 820 medical inpatients, 185 cardiac surgery patients, 134 non-cardiac surgery patients and 502 population-based elderly subjects were included. Mean age was 82 years (SD 7.5 years), 598 (36%) were male, 665 (41%) had pre-existing cognitive impairment, and 558 (34%) experienced delirium. The SLC6A3 rs393795 homozygous AA genotype was more frequent in patients without delirium in all populations. The meta-analysis showed an Odds Ratio (OR) for delirium of 0.4 (95% confidence interval (C.I.) 0.2-0.6, P = 0.0003) for subjects with AA genotype compared to the AG and GG genotypes. SLC6A3 marker rs1042098 showed no association with delirium. In meta-analysis the DRD2 rs6276 homozygous GG genotype showed an OR of 0.8 for delirium (95% C.I. 0.6-1.1, P = 0.24). When subjects were stratified for cognitive status the rs6276 GG genotype showed ORs of 0.6 (95% C.I. 0.4-1.0, P = 0.06) and 0.8 (95% C.I. 0.5-1.5, P = 0.51) for delirium in patients with and without cognitive impairment, respectively. In independent cohorts, a variation in the SLC6A3 gene and possibly the DRD2 gene were found to protect for delirium.

Undecylenic acid: a valuable and physiologically active renewable building block from castor oil.

A lot of attention is currently being paid to the transition to a biobased economy. In this movement, most efforts concentrate on the development of bioenergy applications including bioethanol, biodiesel, thermochemical conversion of biomass, and others. However, in the energy sector other nonbiomass alternatives are known, whereas no valuable alternatives are available when thinking about chemical building blocks. Therefore, it is also essential to develop new routes for the synthesis of bio-based chemicals and materials derived thereof. Such intermediates can originate either from plants or from animals. Castor oil is a non-edible oil extracted from the seeds of the castor bean plant Ricinus communis (Euphorbiaceae), which grows in tropical and subtropical areas. Globally, around one million tons of castor seeds are produced every year, the leading producing areas being India, PR China, and Brazil.2 10-Undecenoic acid or undecylenic acid is a fatty acid derived from castor oil that, owing to its bifunctional nature, has many possibilities to develop sustainable applications.

Reproducibility of the ambulatory arterial stiffness index in hypertensive patients.

BACKGROUND: We studied the repeatability of the ambulatory arterial stiffness index (AASI), which can be computed from 24-h blood pressure (BP) recordings as unity minus the regression slope of diastolic on systolic BP. METHODS: One hundred and fifty-two hypertensive outpatients recruited in Nijmegen (mean age = 46.2 years; 76.3% with systolic and diastolic hypertension) and 145 patients enrolled in the Systolic Hypertension in Europe (Syst-Eur) trial (71.0 years) underwent 24-h BP monitoring at a median interval of 8 and 31 days, respectively. We used the repeatability coefficient, which is twice the SD of the within-participant differences between repeat recordings, and expressed it as a percentage of four times the SD of the mean of the paired measurements. RESULTS: Mean AASI (crude or derived by time-weighted or robust regression) and 24-h pulse pressure (PP) were similar on repeat recordings in both cohorts. In Nijmegen patients, repeatability coefficients of AASI and PP were approximately 50%. In Syst-Eur trial patients, repeatability coefficient was approximately 60% for AASI and approximately 40% for PP. For comparison, repeatability coefficients for 24-h systolic and diastolic BP were approximately 30%. Differences in AASI between paired recordings were correlated with differences in the goodness of fit (r2) of the AASI regression line as well as with differences in the night-to-day BP ratio. However, in sensitivity analyses stratified for type of hypertension, r2, or dipping status, repeatability coefficients for AASI did not widely depart from 50 to 60% range. CONCLUSION: Estimates of mean AASI were not different between repeat recordings, and repeatability coefficients were within the 50-60% range.

Side effects of ambulatory blood pressure monitoring.

OBJECTIVE: To study the experiences and complaints of patients who underwent 24 h blood pressure monitoring. METHODS: Two groups of hypertensive patients of a tertiary outpatient clinic were asked to fill in a nine-item questionnaire about the side effects of ambulatory blood pressure monitoring (ABPM). The first group (n=75) used the auscultatory Oxford Medilog device (OM) and the second group (n=110) the oscillometric Spacelabs 90207 (SL). RESULTS: The OM showed significantly less error readings (OM versus SL, 9 versus 19%; P=0.005) but was also less tolerated by the subjects. Sleep disturbance was noted in 53% of the OM patients group in comparison with 18% in the SL group (P<0.0001). Adjustment of daily activities occurred more often in the OM group (OM versus SL, 37 versus 19%; P=0.013) as did complaints of pain in the cuffed arm (OM versus SL, 31 versus 11 %; P=0.007). There was no difference in the proportion of patients that refused a second ABPM (OM versus SL, 11 versus 10%). Linear regression analyses showed that differences in side effects between the two devices were not due to differences in blood pressure, heart rate, age or sex. CONCLUSIONS: This study demonstrates that side effects of ABPM are not negligible and that there are differences between devices.