In situ simulation in the intensive care unit: A phenomenological study of staff experiences.

OBJECTIVE: To explore the experiences of clinical and non-clinical staff in an intensive care unit regarding the perceived benefits and drawbacks of using in situ simulation as a training tool. METHODS: A descriptive phenomenological qualitative study was conducted among clinical and nonclinical ICU personnel. Simulations and interviews were conducted until data saturation was achieved. The interviews were recorded, transcribed verbatim for analysis, and interpreted using the Colaizzi method. RESULTS: Ten participant interviews generated data saturation. ISS was found to be feasible and beneficial in the ICU, facilitating experiential and emotion-based learning in real-world environments. Eight result categories were identified: simulation benefits, simulation benefits in real conditions, scenario authenticity, interference with usual work, ISS sessions, high-fidelity generating affective bonding, ISS as knowledge reinforcement, and recommendations for improvement. The fundamental structure revealed that ISS is perceived as an authentic and emotionally impactful team simulation modality that promotes experiential learning, reflection, and care improvement opportunities within the complex sociotechnical system of the ICU. CONCLUSIONS: All interviewees considered ISS to be a feasible simulation tool that should be implemented in the ICU to improve knowledge and skills, thereby enhancing teamwork.

Physiological and clinical effects of trunk inclination adjustment in patients with respiratory failure: a scoping review and narrative synthesis.

BACKGROUND: Adjusting trunk inclination from a semi-recumbent position to a supine-flat position or vice versa in patients with respiratory failure significantly affects numerous aspects of respiratory physiology including respiratory mechanics, oxygenation, end-expiratory lung volume, and ventilatory efficiency. Despite these observed effects, the current clinical evidence regarding this positioning manoeuvre is limited. This study undertakes a scoping review of patients with respiratory failure undergoing mechanical ventilation to assess the effect of trunk inclination on physiological lung parameters. METHODS: The PubMed, Cochrane, and Scopus databases were systematically searched from 2003 to 2023. INTERVENTIONS: Changes in trunk inclination. MEASUREMENTS: Four domains were evaluated in this study: 1) respiratory mechanics, 2) ventilation distribution, 3) oxygenation, and 4) ventilatory efficiency. RESULTS: After searching the three databases and removing duplicates, 220 studies were screened. Of these, 37 were assessed in detail, and 13 were included in the final analysis, comprising 274 patients. All selected studies were experimental, and assessed respiratory mechanics, ventilation distribution, oxygenation, and ventilatory efficiency, primarily within 60 min post postural change. CONCLUSION: In patients with acute respiratory failure, transitioning from a supine to a semi-recumbent position leads to decreased respiratory system compliance and increased airway driving pressure. Additionally, C-ARDS patients experienced an improvement in ventilatory efficiency, which resulted in lower PaCO2 levels. Improvements in oxygenation were observed in a few patients and only in those who exhibited an increase in EELV upon moving to a semi-recumbent position. Therefore, the trunk inclination angle must be accurately reported in patients with respiratory failure under mechanical ventilation.

Effects of changes in trunk inclination on ventilatory efficiency in ARDS patients: quasi-experimental study.

BACKGROUND: Trunk inclination from semirecumbent head-upright to supine-flat positioning reduces driving pressure and increases respiratory system compliance in patients with acute respiratory distress syndrome (ARDS). These effects are associated with an improved ventilatory ratio and reduction in the partial pressure of carbon dioxide (PaCO2). However, these physiological effects have not been completely studied, and their mechanisms have not yet been elucidated. Therefore, this study aimed to evaluate the effects of a change in trunk inclination from semirecumbent (45°) to supine-flat (10°) on physiological dead space and ventilation distribution in different lung regions. RESULTS: Twenty-two ARDS patients on pressure-controlled ventilation underwent three 60-min steps in which trunk inclination was changed from 45° (baseline) to 10° (intervention) and back to 45° (control) in the last step. Tunk inclination from a semirecumbent (45°) to a supine-flat (10°) position resulted in a higher tidal volume [371 (± 76) vs. 433 (± 84) mL (P < 0.001)] and respiratory system compliance [34 (± 10) to 41 (± 12) mL/cmH2O (P < 0.001)]. The CO2 exhaled per minute improved from 191 mL/min (± 34) to 227 mL/min (± 38) (P < 0.001). Accordingly, Bohr's dead space ratio decreased from 0.49 (± 0.07) to 0.41 (± 0.06) (p < 0.001), and PaCO2 decreased from 43 (± 5) to 36 (± 4) mmHg (p < 0.001). In addition, the impedance ratio, which divides the ventilation activity of the ventral region by the dorsal region ventilation activity in tidal images, dropped from 1.27 (0.83-1.78) to 0.86 (0.51-1.33) (p < 0.001). These results, calculated from functional EIT images, indicated further ventilation activity in the dorsal lung regions. These effects rapidly reversed once the patient was repositioned at 45°. CONCLUSIONS: A change in trunk inclination from a semirecumbent (45 degrees) to a supine-flat position (10 degrees) improved Bohr's dead space ratio and reduced PaCO2 in patients with ARDS. This effect is associated with an increase in tidal volume and respiratory system compliance, along with further favourable impedance ventilation distribution toward the dorsal lung regions. This study highlights the importance of considering trunk inclination as a modifiable determinant of physiological parameters. The angle of trunk inclination is essential information that must be reported in ARDS patients.

Physiological and inflammatory consequences of high and low respiratory rate in acute respiratory distress syndrome.

Using protective mechanical ventilation strategies with low tidal volume is usually accompanied by an increment of respiratory rate to maintain adequate alveolar ventilation. However, there is no robust data that support the safety of a high respiratory rate concerning ventilator-induced lung injury. Several experimental animal studies have explored the effects of respiratory rate over lung physiology, using a wide range of frequencies and different models. Clinical evidence is scarce and restricted to the physiological impact of increased respiratory rate. Undoubtedly, the respiratory rate can influence respiratory mechanics in various ways as a factor of multiplication of the power of ventilation, and gas exchange, and also on alveolar dynamics. In this narrative review, we present our point of view over the main experimental and clinical evidence available regarding the effect of respiratory rate on ventilator-induced lung injury development.

[Augmented renal clearance in critically ill patients: incidence, associated factors and effects on vancomycin treatment]. / Incremento da depuração renal em pacientes gravemente enfermos: incidência, fatores associados e efeitos no tratamento com vancomicina.

OBJECTIVE: An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the effects on vancomycin concentrations and dosing in a series of intensive care unit patients. METHODS: We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3 mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120 mL/min/1.73 m²), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered. RESULTS: Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p<0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations. CONCLUSIONS: In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.

Incremento da depuração renal em pacientes gravemente enfermos: incidência, fatores associados e efeitos no tratamento com vancomicina / Augmented renal clearance in critically ill patients: incidence, associated factors and effects on vancomycin treatment

Objetivo: Foi descrito um incremento da depuração renal em alguns grupos de pacientes gravemente enfermos, o qual pode induzir à eliminação de concentrações de fármacos por filtração glomerular aquém do ideal, principalmente no caso de antibióticos. Sua ocorrência e os fatores determinantes têm sido pouco estudados. Nossos objetivos foram determinar a incidência e os fatores associados ao incremento da depuração renal, bem como seus efeitos nas concentrações e na posologia de vancomicina em uma série de pacientes em unidade de terapia intensiva. Métodos: Estudamos, de forma prospectiva, 363 pacientes admitidos durante 1 ano em uma unidade de terapia intensiva clínico-cirúrgica. Foram excluídos pacientes que tivessem nível de creatinina sérica >1,3mg/dL. A depuração de creatinina foi calculada a partir da coleta de urina de 24 horas. Os pacientes foram agrupados segundo a presença de incremento da depuração renal (depuração de creatinina >120mL/min/1,73m2), e os possíveis fatores de risco foram analisados por meio de análise bivariada e logística. Em pacientes tratados com vancomicina, foram registradas a posologia e as concentrações plasmáticas. Resultados: O incremento da depuração renal esteve presente em 103 pacientes (28%), os quais eram mais jovens (48±15 versus 65±17 anos; p<0,0001), tinham mais frequentemente admissões obstétricas (16 versus 7%; p=0,0006) e por trauma (10 versus 3%; p=0,016), e menos comorbidades. Os únicos determinantes independentes para o desenvolvimento de incremento da depuração renal foram idade (OR=0,95; IC95%=0,93-0,96; p<0,0001;) e ausência de diabetes (OR 0,34; IC95% 0,12-0,92; p=0,03). Doze dos 46 pacientes que receberam vancomicina tinham ...

Objective: An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the effects on vancomycin concentrations and dosing in a series of intensive care unit patients. Methods: We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m2), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered. Results: Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p<0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations. Conclusions: In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing. .