Assessment of Dyspnea in Critically Ill Patients: A Comparative Analysis of Evaluation Scales.

Purpose This study aimed to evaluate the Respiratory Distress Observation Scale (RDOS), Intensive Care RDOS (IC-RDOS), and Mechanical Ventilation RDOS (MV-RDOS) as potential markers of dyspnea in ICU patients by describing their relationship with the Dyspnea Visual Analog Scale (D-VAS). Materials and methods A researcher and a trained nurse independently assessed ICU patients simultaneously. One researcher assessed the RDOS (IC/MV-RDOS) and the depth of sedation. An objective evaluation using the observational D-VAS was simultaneously performed by a trained nurse. Results The correlation coefficients for each scale were 0.338 for the D-VAS and RDOS, 0.239 for the IC-RDOS, and 0.237 for the MV-RDOS, indicating a low correlation. The prediction of self-reported dyspnea showed that each scale's area under the curve (AUC) as a predictor of D-VAS ≥4 was 0.79 (95% Confidence Interval [CI] 0.71-0.87) for RDOS, 0.77 (95% CI 0.68-0.84) for IC-RDOS, and 0.73 (95% CI 0.64-0.81) for MV-RDOS. Conclusions The objective rating scales RDOS, IC-RDOS, and MV-RDOS can predict subjective dyspnea to a certain extent; however, they have limitations in accurately discriminating dyspnea intensity.

Early Light Sedation Increased the Duration of Mechanical Ventilation in Patients With Severe Lung Injury.

Introduction: The international guidelines recommend light sedation management for patients receiving mechanical ventilation. One of the benefits of light sedation management during mechanical ventilation is the preservation of spontaneous breathing, which leads to improved gas-exchange and patient outcomes. Conversely, recent experimental animal studies have suggested that strong spontaneous breathing effort may cause worsening of lung injury, especially in severe lung injury cases. The association between depth of sedation and patient outcomes may depend on the severity of lung injury. Objective: This study aimed to describe the patients' clinical outcomes under deep or light sedation during the first 48 h of mechanical ventilation and investigate the association of light sedation on patient outcomes for each severity of lung injury. Methods: The researchers performed a retrospective observational study at a university hospital in Japan. Patients aged ≥20 years, who received mechanical ventilation for at least 48 h were enrolled. Results: A total of 413 patient cases were analyzed. Light sedation was associated with significantly shorter 28-day ventilator-free days compared with deep sedation in patients with severe lung injury (0 [IQR 0-5] days vs. 16 [0-19] days, P = .038). In the groups of patients with moderate and mild lung injury, the sedation depth was not associated with ventilator-free days. After adjusting for the positive end-expiratory pressure and APACHE II score, it was found that light sedation decreased the number of ventilator-free days in patients with severe lung injury (-10.8 days, 95% CI -19.2 to -2.5, P = .012). Conclusion: Early light sedation for severe lung injury may be associated with fewer ventilator-free days.

Impact of adverse events on patient outcomes in a Japanese intensive care unit: a retrospective observational study.

AIM: We investigated adverse events (AEs) in a Japanese intensive care unit (ICU) and evaluated the impact of cause-specific AEs on mortality and length of stay. DESIGN: A retrospective observational study in the ICU of an academic hospital. METHODS: We reviewed medical records with the Global Trigger Tool. RESULTS: Of the 246 patients, 126 (51%) experienced one or more AEs with an incidence of 201 per 1000 patient-days and 115 per 100 admissions. A total of 294 AEs were detected with 119 (42%) adverse drug events, 67 (24%) procedural complications, 63 (22%) surgical complications, 26 (9%) nosocomial infections, 5 (2%) therapeutic errors and 4 (1%) diagnostic errors. Adverse event (AE) presence was associated with length of ICU stay (ß = 2.85, 95% confidence interval [CI]: 1.09-4.61). Adverse drug events, procedural complications and nosocomial infections were strongly associated with length of ICU stay (ß = 2.38, 95% CI: 0.77-3.98; ß = 3.75, 95% CI: 2.03-5.48; ß = 6.52, 95% CI: 4.07-8.97 respectively).

Translation, reliability, and validity of Japanese version of the Respiratory Distress Observation Scale.

Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases and is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." However, Japanese intensive care units (ICUs) do not routinely screen for dyspnea, as no validated Japanese version of the Respiratory Distress Observation Scale (RDOS) is available. Therefore, we aimed to translate the English version of this questionnaire into Japanese and assess its validity and reliability. To translate the RDOS, we conducted a prospective observational study in a 12-bed ICU of a universal hospital that included 42 healthcare professionals, 10 expert panels, and 128 ventilated patients. The English version was translated into Japanese, and several cross-sectional web-based questionnaires were administered to the healthcare professionals. After completing the translation process, a validity and reliability evaluation was performed in the ventilated patients. Inter-rater reliability was evaluated using Cohen's weighted kappa coefficient. Criterion validity was ascertained based on the correlation between RDOS and the dyspnea visual analog scale. The area under the receiver operating characteristic curve analysis was used to evaluate the ability of the RDOS to identify patients with self-reported dyspnea. The average content validity index at the scale level was 0.95. Data from the 128 patients were collected and analyzed. Cohen's weighted kappa coefficient and the correlation coefficient between the two scales were 0.76 and 0.443 (95% confidence intervals 0.70-0.82 and 0.23-0.62), respectively. For predicting self-reported dyspnea, the area under the receiver operating characteristic curve was 0.81 (95% confidence interval 0.67-0.97). The optimal cutoff used was 1, with a sensitivity and specificity of 0.89 and 0.61, respectively. Our findings indicated that the Japanese version of the RDOS is acceptable for face validity, understandability, criterion validity, and inter-rater reliability in lightly sedated mechanically ventilated patients, indicating its clinical utility.

Improving Antibiotic Administration Rate for Patients With Sepsis in the Emergency Department.

BACKGROUND: Previous studies have demonstrated that delayed antibiotic administration increases the risk of mortality in patients with sepsis. LOCAL PROBLEM: In the emergency department, the antibiotic administration rate within 1 and 3 hours for patients with suspected sepsis was low. METHODS/INTERVENTIONS: We implemented an educational intervention with the nursing staff, which included training sessions and feedback, to ensure early detection and management of patients with suspected sepsis. Antibiotic administration rates were compared before and after education. RESULTS: A total of 503 patients were included. The antibiotic administration rate improved as the phases continued (1 hour: from 5.2% to 15.6%, P = .004; 3 hours: from 35.6% to 49.7%, P = .04; 6 hours: from 74.1% to 89.1%, P = .002). The time to initial antibiotic administration also improved from 229 to 185 minutes (P < .001). CONCLUSIONS: Nurse-initiated quality improvement improved the early administration of antibiotics for patients with suspected sepsis.