IntroductionThe aim of this study was to evaluate the incidence and determinants of AKI in a large cohort of cardiac arrest patients.MethodsWe reviewed all patients admitted, for at least 48 hours, to our Dept. of Intensive Care after CA between January 2008 and October 2012. AKI was defined as oligo-anuria (daily urine output <0.5 ml/kg/h) and/or an increase in serum creatinine (≥0.3 mg/dl from admission value within 48 hours or a 1.5 time from baseline level). Demographics, comorbidities, CA details, and ICU interventions were recorded. Neurological outcome was assessed at 3 months using the Cerebral Performance Category scale (CPC 1–2 = favorable outcome; 3–5 = poor outcome).ResultsA total of 199 patients were included, 85 (43%) of whom developed AKI during the ICU stay. Independent predictors of AKI development were older age, chronic renal disease, higher dose of epinephrine, in-hospital CA, presence of shock during the ICU stay, a low creatinine clearance (CrCl) on admission and a high cumulative fluid balance at 48 hours. Patients with AKI had higher hospital mortality (55/85 vs. 57/114, p = 0.04), but AKI was not an independent predictor of poor 3-month neurological outcome.ConclusionsAKI occurred in more than 40% of patients after CA. These patients had more severe hemodynamic impairment and needed more aggressive ICU therapy; however the development of AKI did not influence neurological recovery.

IntroductionCritically ill patients and patients undergoing high-risk and major surgery, are instrumented with intra-arterial catheters and invasive blood pressure is considered the “gold standard” for arterial pressure monitoring. Nonetheless, artifacts due to inappropriate dynamic response of the fluid-filled monitoring systems may lead to clinically relevant differences between actual and displayed pressure values. We sought to analyze the incidence and causes of resonance/underdamping phenomena in patients undergoing major vascular and cardiac surgery.MethodsArterial pressures were measured invasively and, according to the fast-flush Gardner’s test, each patient was attributed to one of two groups depending on the presence (R-group) or absence (NR-group) of resonance/underdamping. Invasive pressure values were then compared with the non-invasive ones.ResultsA total of 11,610 pulses and 1,200 non-invasive blood pressure measurements were analyzed in 300 patients. Ninety-two out of 300 (30.7%) underdamping/resonance arterial signals were found. In these cases (R-group) systolic invasive blood pressure (IBP) average overestimation of non-invasive blood pressure (NIBP) was 28.5 (15.9) mmHg (P <0.0001) while in the NR-group the overestimation was 4.1(5.3) mmHg (P <0.0001). The mean IBP-NIBP difference in diastolic pressure in the R-group was −2.2 (10.6) mmHg and, in the NR-group −1.1 (5.8) mmHg. The mean arterial pressure difference was 7.4 (11.2) mmHg in the R-group and 2.3 (6.4) mmHg in the NR-group. A multivariate logistic regression identified five parameters independently associated with underdamping/resonance: polydistrectual arteriopathy (P =0.0023; OR = 2.82), history of arterial hypertension (P =0.0214; OR = 2.09), chronic obstructive pulmonary disease (P =0.198; OR = 2.61), arterial catheter diameter (20 vs. 18 gauge) (P <0.0001; OR = 0.35) and sedation (P =0.0131; OR = 0.5). The ROC curve for the maximal pressure–time ratio, showed an optimum selected cut-off point of 1.67 mmHg/msec with a specificity of 97% (95% CI: 95.13 to 99.47%) and a sensitivity of 77% (95% CI: 67.25 to 85.28%) and an area under the ROC curve by extended trapezoidal rule of 0.88.ConclusionPhysicians should be aware of the possibility that IBP can be inaccurate in a consistent number of patients due to underdamping/resonance phenomena. NIBP measurement may help to confirm/exclude the presence of this artifact avoiding inappropriate treatments.

Psychometric Evaluation of a Measure of Factors Influencing Hand Hygiene Behaviour to Inform Intervention Background. Although the hand hygiene (HH) procedure is simple, the related behaviour is complex and is not readily understood, explained, or changed. There is a need for practical tools to provide data that can guide healthcare managers and practitioners not only on the 'what' (the standards that must be met), but also the 'how' (guidance on how to achieve the standards). Aim. To develop a valid questionnaire to evaluate attitudes to the factors that influence engagement in HH behaviour that can be readily completed, administered, and analysed by healthcare professionals to identify appropriate intervention strategies. Construct validity was assessed using confirmatory factor analysis, predictive validity through comparison with selfreported HH behaviour, and convergent validity through direct unit-level observation of HH behaviour. Methods. The Capability, Opportunity, Motivation-Behaviour (COM-B) model was used to design a 25-item questionnaire that was distributed to Intensive Care Unit (ICU) personnel in Ireland. Direct observation of HH behaviour was carried out at two ICUs. Findings. A total of 292 responses to the survey (response rate 41.0%) were included in the analysis. Confirmatory factor analysis resulted in a 17-item questionnaire. Multiple regression revealed that a model including Capability, Opportunity, and Motivation, was a significant predictor of self-reported Behavioural intention (F(3,209) =22.58, p<0.001). However, the Opportunity factor was not found to make a significant contribution to the regression model. Conclusion. The COMB HH questionnaire is reliable and valid and provides data to support the development, and evaluation, of HH interventions that meet the needs of specific healthcare units.

Background: Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COMB) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance. Methods: A semi-structured interview schedule was developed based upon the COMB model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers. Results: Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees-particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved. Conclusions: This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.

AKI occurred in >10% of patients after SAH. These patients had more severe neurological impairment and needed more aggressive ICU therapy; AKI did not significantly influence outcome.

Biomarkers are widely used to confirm the presence of infection. However, it would be of the greatest importance to predict in advance the occurrence or worsening of organ dysfunction in infected patients allowing timely antibiotic escalation. This study investigates the ability of procalcitonin (PCT) and MR-proADM to predict the transition to sepsis in infected patients. The study was conducted in a neurointensive care unit over a three-month period. We included both patients with and without infection to investigate the specificity of organ dysfunction prediction in infected patients. Daily measurement of PCT and MR-proADM, SOFA, Pitt, and CPIS were performed. To measure the correlation between each biomarker and each severity score, linear mixed-effects models were developed. For each biomarker-score combination we tested the correlation of the score with the biomarker measured one and two days before, the same day, and the day after. Sixty-four critically ill patients, 31 with infection, were enrolled. The statistically significant biomarker-score combinations were PCT-SOFA, MR-proADM-SOFA, MR-proADM-Pitt, and MR-proADM-CPIS. The MR-proADM models predicting Pitt and CPIS variations with 24-hour anticipation showed the best fit. The scores increased by 0.6 ± 0.3 and 0.4 ± 0.2 for each unitary biomarker increase, respectively. The MR-proADM-SOFA combinations were equivalent when the biomarker was measured the day before or the same day (score increases were 1.5 ± 0.4 and 1.9 ± 0.4, respectively). The PCT-SOFA model had the best fit when PCT was measured the same day of the score. There was no difference in the predictive ability of the biomarker in infected and non-infected patients. This was a pivotal study conducted in a single neurointensive centre on a limited number of patients, and as such it does not provide definitive conclusions. PR-proADM predicted occurrence and worsening of organ failure in critically ill patients with and without infection. The combination with infection diagnostic biomarkers such as PCT would allow predicting evolution to sepsis in infected patients.

Near-infrared spectroscopy (NIRS) has been used to detect in vivo microvascular alterations by means of a vascular occlusion test. We sought to analyse by NIRS the microcirculatory profile of patients undergoing prolonged tourniquet-induced bloodless condition for extremity surgery, and compare the results with time of ischemia and comorbidities. We conducted a prospective observational study on 42 patients undergoing upper limb surgery. Regional anaesthesia was achieved and ischemia was induced by a tourniquet cuffed at 250 mmHg. The probe of a NIRS monitor (InSpectra 325, Hutchiston, USA) was placed on the brachial muscle, and muscle oxygen saturation (StO 2 ) was recorded continuously before anaesthesia, during and after surgery. The following variables were recorded: baseline StO 2 , StO 2 desaturation slope during occlusion (dSlope, units/s), resaturation rate following ischemia (RR, units/s), hyperaemic peak (peak, units), and duration of the hyperaemic period following ischemia (hyperaemic time, s). Values of dSlope were similar among all patients. RR and hyperaemic time were significantly correlated with the duration of ischemia, but not with comorbidities [p = 0.007 CI (-35.64 to -13.1), and p \ 0.001 CI (0.049-0.159), respectively]. Grouping patients by duration of ischemia (30, 60, or 90 min), we found a significant decrease in RR after 60 and 90 min (p \ 0.001 and p = 0.03, respectively). Hyperaemic peak was lower in the 90 min group (83.9 ± 6.8 vs.91.2 ± 5.7 %, p = 0.02) whereas the hyperaemic time was significantly increased (595 ± 136 vs. 429 ± 107 min, p \ 0.001). Alterations of skeletal muscle microcirculation were correlated with the duration of ischemia, but not with comorbidities. We observed an initial impairment of the microcirculatory recovery at 90 min of ischemia.

Coagulopathy has proven to be a common complication of the novel coronavirus SARS-CoV-2, with evidence of elevated D-dimers and fibrin degradation products associated with an increased incidence of thromboembolism. Despite emerging evidence describing the coagulopathy and its clinical relevance in COVID-19, fewer studies have addressed the potential role of empiric therapeutic anticoagulation in this setting. We report the case of a patient admitted to our intensive care unit (ICU) with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19 whose clinical trajectory improved dramatically after initiation of a therapeutic dose of LMWH. The patient showed progressive elevation of fibrinogen and D-dimers despite a prophylactic dose of LMWH during her ICU stay. This was met with a moderate increase of troponin T-hs, an escalating need for vasopressors, and a progressive decrease in her P/F ratio despite preserved lung static compliance. Her platelet count was normal and had an elevated fibrinogen during the first week of ICU stay. The ECG was normal, and a bedside transthoracic echocardiogram showed no evidence of pulmonary embolism and a preserved EF with no regional wall motion abnormalities (RMWA). The chest X-ray was not dissimilar to previous exams, and the ABG showed hypoxia with normal pCO2 values. The decision was made to commence empiric therapeutic enoxaparin. The patient did not experience bleeding complications, and her clinical trajectory appeared to change dramatically. She was successfully extubated three days later and proceeded to clinical recovery and eventual discharge from the ICU. The available evidence shows that there is undoubtedly coagulopathy associated with COVID-19 with various subsequent forms of clinical manifestation described in the literature. Evidence also shows the benefits of heparin as an anticoagulant. From the discussion of this case report, however, it can be concluded that despite the plausible theoretical rationale, studies pertaining to the role of empiric therapeutic anticoagulation in this setting fall short of providing compelling evidence. Subsequently the role of empiric therapeutic anticoagulation in COVID-19 remains unclear with a pressing call for further research.