Intensive Care Society

Psychological trauma, such as witnessing an untimely or gruesome death, commonly provokes intrusive memories that might persist for days to years with adverse effects on individual mental and physical health and functioning. Despite the global prevalence of trauma, scalable evidence-based interventions are absent. Reducing the impact of intrusive memories is crucial for people frequently exposed to trauma, such as health-care workers. This study aimed to determine whether a brief digital imagery-competing task intervention (ICTI) reduced intrusive memory frequency after 4 weeks. Harms were also assessed. The GAINS-02 decentralised digital, parallel-group Bayesian adaptive randomised controlled trial tested a brief ICTI against an active control and treatment as usual to determine the effect on reducing intrusive memory frequency. Health-care workers in facilities that admitted patients with COVID-19 during the pandemic, who had experienced one or more traumatic events and reported at least three intrusive memories in the week before screening were randomised 2:2:1 (ICTI to active control to treatment as usual) via block randomisation (web-based). ICTI and active control participants were masked to treatment allocation, and both had one guided session then optional self-use. ICTI involved image-based memory retrieval then Tetris computer gameplay with mental rotation. The active control involved a music-listening task. Study statisticians were masked to ICTI and active control group. The primary outcome was the number of intrusive memories in week 4 (controlling for baseline), which was evaluated on an intention-to-treat basis. Treatment effects for the intervention group versus the comparator groups were assessed using Bayes regression analyses. Harms were assessed through adverse event reporting and interim analyses on primary outcome. People with lived experience were involved from study conception and throughout the research and writing process. The trial was pre-registered at clinicaltrials.gov (NCT05616676) and is completed. Between Dec 8, 2022, and Sept 15, 2023, 176 participants were screened and 99 included (ICTI n=40, active control n=39, treatment as usual n=20) with mean age 41·2 years (SD 10·2; range 21-62). Of these 99 participants, 85 (86%) self-identified as women and 89 (90%) as White. Bayesian analyses gave robust evidence that ICTI reduced intrusive memories at week 4: ICTI participants reported fewer intrusive memories (median 0·5 [IQR 0·0-5·0]) compared with the active control (active control 5·0 [3·0-11·5]; Bayes factor [BF]active control>ICTI vs active control=ICTI 114·1; βactive control>ICTI 1·29 [95% CrI 0·64-2·00]) and treatment as usual (median 5·0 [IQR 2·5-8·0]; BFtreatment as usual>ICTI vs treatment as usual=ICTI=15·8; βtreatment as usual>ICTI 1·21 [95% CrI 0·49-1·98]) groups. No harms were detected for ICTI relative to the active control and treatment as usual. The most reported adverse event (n=7) was COVID-19. Two adverse events involved burden of diary recording. Serious adverse events were hospitalisations unrelated to study procedures (n=6). This study shows that ICTI reduces intrusive memory frequency and post-traumatic stress disorder symptoms among health-care workers exposed to trauma. As a brief, scalable digital intervention, ICTI shows promise for mitigating consequences of trauma on mental health, an important and unmet need for health-care personnel and systems worldwide. Wellcome Trust, Swedish Research Council, UK Medical Research Council, and National Institute for Health and Care Research.

Although videolaryngoscopy is particularly helpful in patients with limited mouth opening, a severely restricted mouth opening is its hardest limitation. This analysis aimed to explore critical lower limits for interincisor distances that optimally predict (i) difficult Macintosh videolaryngoscopy or (ii) the risk of Macintosh videolaryngoscopy failure and may warrant consideration of alternative or awake techniques. This analysis from a prospective observational study includes 192 adults at increased risk for difficult Macintosh videolaryngoscopy undergoing head and neck surgery managed with Macintosh videolaryngoscopy (C-MAC) as the first-choice technique. Interincisor distances were measured before and after anesthesia induction. Five clinical indicators (outcome measures) for difficult Macintosh videolaryngoscopy (multiple attempts, conversion to hyperangulated videolaryngoscopy, documentation of a difficult videolaryngoscopic intubation, hyperangulated videolaryngoscopy recommended for future anesthesia, anesthesia alert card issued) and 2 key indicators for the risk of Macintosh videolaryngoscopy failure (vocal cords not visible, awake flexible endoscopy recommended for future anesthesia) were systematically assessed. Mouth opening was grouped in 2 mm intervals; the Youden index was calculated for each of these intervals and the maximum Youden index (Jmax) was noted for each of the 7 indicator. For each mouth opening interval, the deviation from this maximum Youden index (Jd-max) and the mean Jd-max across all indicators were calculated to identify optimal thresholds. The incidence of difficult videolaryngoscopic intubation was 56.8% (109/192). Optimal discrimination between easy and difficult Macintosh videolaryngoscopy (best mean Jd-max values) was derived from interincisor distances between 23 and 35 mm. The incidence of failed Macintosh videolaryngoscopy was 26.0% (50/192) in our study cohort and showed a clear inverse correlation with the interincisor distance. Discrimination between low and high risk of Macintosh videolaryngoscopy failure was optimal (best mean Jd-max values) between 21 and 23 mm. After anesthesia induction, interincisor distances increased in 31.8% (61/192), remained unchanged in 17.2% (33/192) but decreased in 51.0% (98/192) of the patients. The highest risk of reduction was found in individuals with degenerative cervical joint diseases (odds ratio [OR] = 6.43 [1.27-32.5]; P = .02), the lowest in those with facial fractures (OR = 0.27 [0.08-0.92]; P = .04) compared with a reference category. Our findings suggest that among individuals with expected difficult airway management, interincisor distances below 21 to 23 mm indicate increased risk of Macintosh videolaryngoscopy failure and may warrant alternative or awake techniques. Caution should be exercised as the mouth opening frequently decreases after anesthesia induction. Results should not be extrapolated to routine intubations in noncomplex patients.

<title>Abstract</title> Purpose To evaluate whether N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at 48–72 hours of life predict moderate-to-severe bronchopulmonary dysplasia (msBPD) using a competing risk framework. Methods We conducted a prospective cohort study including infants ≤ 32 weeks of gestation admitted between 2013–2023 to a level III neonatal unit. NT-proBNP was routinely measured at 48–72 hours. Primary outcomes were msBPD (2001 NIH definition) and death before 36 weeks postmenstrual age, analyzed using Fine and Gray competing risk regression. Secondary analyses included cumulative incidence of successful extubation by day 28 and sensitivity analyses restricted to infants surviving beyond 14 days. Models were adjusted for gestational age (GA) and other clinically relevant covariates. Results Among 264 included infants with a median (IQR) gestational age and birth weight of 30 [27.5–31.5] weeks and 1230 [981–1568] g) respectively, 38 (14.4%) developed msBPD and 18 (6.8%) died. NT-proBNP was not associated with msBPD in univariate [subdistribution hazard ratio (SHR) 1.03, 95% confidence interval (CI) 0.79–1.34; p = 0.84] or adjusted models. Conversely, NT-proBNP independently predicted death [adjusted SHR 2 (95% CI 1.2–3.2); p = 0.008). NT-proBNP was also associated with a reduced chance of successful extubation [adjusted SHR 0.88, (95% CI 0.8–0.98); p = 0.027). In infants surviving &gt; 14 days, NT-proBNP showed a modest association with msBPD [adjusted SHR 1.3 (95% CI 1.01–1.73); p = 0.042). Conclusion Early NT-proBNP is primarily a marker of early mortality risk rather than a specific predictor of msBPD. Competing risk methods are essential to avoid overestimating biomarker utility in bronchopulmonary dysplasia (BPD) prediction.

Background: Critical illness increases the risk of malnutrition, which can increase infections, prolong mechanical ventilation, delay recovery, and increase mortality. This study aimed to compare the intensive care outcomes based on initiation of parenteral nutrition (PN)) within 7 days versus after 7 days of poor nutrient intake in critically-ill adult patients. Methods: This multicenter parallel group randomized controlled trial included 100 included patients who were recruited from the critical care units at Benha University hospital and Cairo Fatemic hospital within six months. Patients divided into two equal groups: Group A (n=50): Patients were assigned for early PN. Group B (n=50): Patients were assigned for late PN. Results: The outcome was significantly different between both groups, showing significantly higher improved cases among patients who received early PN compared to those who received late PN (P=0.015). Conclusion: Initiation of PN within 7 days led to more improved cases compared to PN after 7 days intensive care for critically-ill adult patients, but with higher acute physiology and chronic health evaluation score.

Guidelines recommend avoiding preoperative anxiolytic medication with midazolam. However, the risk-benefit ratio of preoperative midazolam prescriptions remains unclear. This study aimed to investigate the association between preoperative midazolam prescription and perioperative in-house mortality as well as preoperative cardiovascular stress. We performed a retrospective single-center propensity score-matched study in a university hospital in Germany before and after de-implementation of routine oral preoperative midazolam prescription in December 2018. We included adult patients who underwent general anesthesia between December 1, 2017, and November 31, 2019. Patients who received midazolam premedication before de-implementation were compared to those who did not receive midazolam after de-implementation. After propensity score matching, we estimated the treatment effects using regression modeling. The primary endpoint was inhospital mortality after general surgery. Secondary endpoints included pre-induction vital signs, duration of stay in the postanesthesia care unit, and medications administered. After propensity score matching, we analyzed 7421 patients in each group. In this adjusted analysis, premedication with midazolam was not associated with mortality (OR 0.91, 95% CI 0.60 to 1.38, p = 0.662). Midazolam premedication was associated with significantly lower pre-induction blood pressures, with an estimated average treatment effect for systolic blood pressure of - 5.33mmHg (SE 0.41, 95% CI - 6.13 to - 4.52mmHg). Midazolam prescription was not associated with increased mortality in a large cohort of surgical patients but with a lower pre-induction blood pressure and heart rate, suggesting a potential reduction in cardiovascular stress.

Eligible donation after brain death (DBD) donors may rarely proceed via the donation after circulatory death (DCD) pathway. The incidence, reasons for pathway divergence, and graft and recipient outcomes in the United Kingdom of this cohort are unknown. We aimed to establish the incidence of eligible DBD to DCD donors in the United Kingdom, the reasons for pathway divergence, organ donation and utilization rates, and the renal graft and recipient outcomes for this cohort. UK electronic and article records were reviewed for all eligible DBD donors proceeding via the DCD pathway from 2012 to 2022. Incidence and stated reasons for pathway divergence, including direct family quotations and time to mechanical asystole, were recorded. These data, in addition to organ donation and utilization rates and those pertaining to renal graft and recipient survival rates, were compared with "standard DCD" and "standard DBD" control groups. One hundred twenty-three eligible DBD donors proceeded via the DCD pathway, overwhelmingly due to a familial desire to be present at mechanical asystole. Median time to asystole was comparable between the cohort and DCD control groups, but the range of times was considerably shorter in the cohort group. Donation and utilization rates were similar between all groups except for the notably lower rates in liver donation for DCD control. Graft and recipient survival rates were similar for all groups, but there was a nonsignificant reduction in delayed graft function (DGF) for the cohort versus DCD control and a significant reduction in DGF for the DBD versus DCD control groups. Eligible DBD donors proceeding via the DCD pathway is a rare event in the United Kingdom and overwhelmingly occurs due to a familial desire to witness asystole. This cohort proceeded to asystole more reliably within acceptable time periods for donation, have higher donation and utilization rates for liver grafts, and may show reduced rates of DGF for renal grafts versus "standard DCD" groups.

Oral propranolol is the first-line treatment for problematic infantile hemangiomas (IHs) requiring systematic therapy. Several retrospective studies have reported the successful treatment of facial IHs with propranolol. In this study, the authors conducted a prospective trial to evaluate the long-term outcomes of oral propranolol use in patients with facial IHs. The primary outcome was the clinical response 4 years after treatment. A total of 272 patients were analyzed, including 38 patients (14.0%) with ulcerated IHs. Four years after treatment, propranolol treatment had resulted in no/minimal sequelae in 232 patients (85.3%). A total of 265 patients (97.4%) reported a durable response to propranolol therapy. Major rebound occurred in 16.9% of patients after propranolol discontinuation. Additional surgery and laser treatment were required in 8.1% and 8.8% of patients, respectively. Logistic regression analyses revealed that age 3 months or older (95% CI, 1.488 to 31.023; P = 0.013), nasal IH (95% CI, 2.143 to 97.571; P = 0.006), and hemangioma ulceration (95% CI, 2.673 to 49.034; P = 0.001) were independent factors predictive of long-term severe/significant sequelae. Segmental subtype (95% CI, 2.081 to 45.597; P = 0.004), mixed IH (95% CI, 3.249 to 26.841; P < 0.001), and lip IH (95% CI, 2.224 to 92.278; P = 0.005) were independent risk factors for major rebound. In this large cohort of patients with facial IHs, propranolol treatment was effective and induced no/minimal sequelae at 4 years after treatment. However, long-term severe/significant sequelae and major rebound after propranolol treatment remain challenges.

A 5-day-old neonate was admitted with chest radiograph showing right-lung opacification. This, together with a severe adenovirus (AdV) viremia (11.8 million copies/mL), indicated severe adenovirus pneumonitis. She was given extracorporeal membrane oxygenation (ECMO), steroids and intravenous cidofovir. After clearing her AdV and 33 days of ECMO, she continued to require nocturnal ventilator support, after transfer back to her local hospital.