Few digital health interventions are currently used in the rehabilitation of ICU patients, despite growing interest in innovative approaches such as exergaming. We aimed to determine the requirements for a therapeutic exergaming system for use in ICU patients. A cross-sectional survey was developed through iterative feedback from a multidisciplinary panel of ICU professionals. The survey was distributed online among ICU professionals using convenience and snowball sampling. The survey was completed by 106 ICU professionals from 16 different countries across four continents. The willingness to use a therapeutic exergaming system to increase physical activity in ICU patients was high, with a median score of 9 (interquartile range: 7-10) on a 0-10 scale. System features rated as very important or absolutely essential included ease of use (85%), patient enjoyment (85%), increasing the patients' motivation for physical activity and mobility (84%), and the ease of transportation (82%). Respondents emphasized adaptability to physical, cognitive, and sensory impairments, suitability for bedridden patients, and ease of integration within the ICU environment, including hygiene, mobility, and space constraints. Over 80% of respondents (strongly) agreed with most proposed benefits of therapeutic exergaming, including stimulation of active participation (94%), activation of patients with ICU-acquired weakness or prolonged immobilization (91%), distraction from the ICU environment (91%), and improved patient motivation to engage in rehabilitation (82%). This survey identifies key requirements for the development of therapeutic exergaming systems and supports their potential role in ICU mobilization when designed to complement existing rehabilitation practices and the intensive care context.

OBJECTIVES:To assess the association between emergency department (ED)-to-ICU transfer time and hospital mortality across common ICU diagnoses. DESIGN, SETTING, AND PATIENTS:Secondary analysis of a Dutch retrospective cohort (2009-2020). Twelve hospitals (four academic and eight nonacademic teaching [NACT]) provided ED arrival and ICU admission times. Adult patients directly admitted from the ED to the ICU were included. Seven diagnostic groups (> 1500 patients each) were analyzed: out-of-hospital cardiac arrest (OHCA), nonoperative trauma, overdose, sepsis, pneumonia, respiratory failure (excluding pneumonia), and intracranial hemorrhage (ICH). Logistic regression assessed associations between ED-to-ICU time quintiles and hospital mortality, adjusting for hospital of admission, and Acute Physiology and Chronic Health Evaluation III score. Analyses were stratified by hospital type. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Among 18,798 patients, median ED-to-ICU time was 1.9 hours (interquartile range, 1.2-3.1 hr). In OHCA ( n = 3,818), associations differed by hospital type. In academic hospitals, prolonged ED-to-ICU time was associated with higher mortality (odds ratio [OR], 1.48; 95% CI, 1.08-2.02 at 1.1-1.6 hr; OR, 2.94; 95% CI, 1.80-4.78 at > 3.4 hr; Wald χ 2p < 0.001). In NACT hospitals, prolonged ED-to-ICU time was negatively associated with mortality, with ORs less than 1.0 across quintiles (Wald χ 2p < 0.001). In nonoperative trauma, a positive association between ED-to-ICU time and hospital mortality was observed in the overall cohort (OR, 1.90; 95% CI, 1.12-3.21 at > 3.4 hr; Wald χ 2p = 0.05) but was not reproduced after stratification for hospital. No associations were observed in overdose, sepsis, pneumonia, respiratory failure, or ICH. CONCLUSIONS:The association between ED-to-ICU time and hospital mortality varied across diagnostic groups and hospital types. In OHCA, opposing associations were observed in academic and NACT hospitals. In nonoperative trauma, a positive association was observed only in the overall cohort. Prospective studies in homogeneous, risk-defined subgroups with detailed process-of-care data are needed to identify modifiable delays and define transfer-time thresholds.

This case report describes the successful treatment of a suicide attempt involving the ingestion of a supralethal dose of sodium azide (NaN3), presenting a prospective novel antidote and therapeutic approach. Treatment encompassed the implementation of high-volume continuous veno-venous hemofiltration (HV-CVVH) alongside the administration of levocarnitine. The latter demonstrated a substantial mitigation of lactate concentration. Comprehensive analyses of serum, ultrafiltrate, and urine revealed the efficacy of HV-CVVH in elimination of NaN3. Our case report presents a potential therapeutic approach for managing otherwise fatal NaN3 intoxications.

OBJECTIVES:To develop a new ICU-distress thermometer to characterize problems as perceived by individual patients and to evaluate it's potential usability in the follow-up of ICU survivors. METHODS:An ICU-distress thermometer was developed through an iterative process involving several discussions with healthcare professionals and ICU survivors. Patients surviving the ICU with an ICU length of stay > 48 h were included and their scores on the instrument were used to assess internal consistency. We assessed the ICU-distress thermometer's usefulness and the burden experienced by ICU patients at specific time points: before ICU admission and 3, 6 and 12 months after hospital discharge. RESULTS:We included a total of 280 ICU patients from four ICUs in the Netherlands between 2020 and 2022. The ICU-distress thermometer showed good to excellent internal reliability i.e. Cronbach's α for the total symptom score (41 items) was good - excellent between 0.901 and 0.945 and was easily used by patients at ICU-follow up out-clinics. It helped focus conversations on patient's complaints. The perceived distress score increased at 3 months after hospital discharge (median 5 [3.3-7]); compared to baseline (median 1 [0-4]; P < 0.001), stabilized between 3-6 months (median 5 [2.5-6]; P = 0.012) and decreased at 12 months (median 3 [2-6]; P = NS). Patients reported changes in perceived problems resulting in a functional decline such as muscle weakness or pain. CONCLUSIONS:The ICU-distress thermometer is a valuable tool with good internal consistency that prevents overwhelming patients with numerous high quality, but non-focussed validated surveys. It improves insight in individually perceived relevant problems and focus specific support needs of ICU survivors during their recovery phase. IMPLICATIONS FOR CLINICAL PRACTICE:The novel ICU-distress thermometer is helpful during ICU follow-up to gain insight in the spectrum and extent of the sources of distress to facilitate appropriate care support and focussed referrals.

Background:Dysphagia is common in intensive care unit (ICU) patients. Using surface electromyography (sEMG) signals as biofeedback training exercises might offer a promising path to improving swallowing function. The Rephagia biofeedback system uses sEMG to assess muscle strength, stamina, and timing of the swallowing action. objectives:The aim of this study was to evaluate the feasibility of the Rephagia system in ICU patients with dysphagia. Methods:This feasibility study included patients admitted to a 14-bed mixed medical-surgical ICU. All patients underwent a new tracheostomy placement during ICU stay due to persistent aspiration and ICU-acquired weakness, accompanied by verified dysphagia. Following Rephagia training, patients completed a questionnaire assessing comprehension, satisfaction, and motivation. Swallowing characteristics were assessed via mean sEMG peak values during exercise. Results:Twenty patients with a mean age of 69.4 (SD 8.2) years were included. The means of sEMG values at the beginning of a measurement were not significantly different at baseline versus everyone's last measurement (52 µV [23 µV] vs 57 µV [22 µV]; P=.50). The means of sEMG values obtained at the end of a measurement were not significantly different at baseline versus everyone's last measurement (56 µV [18 µV] vs 59 µV [23 µV]; P=.62). However, dysphagia improved in all patients. Patients understood the importance of the game in relation to their swallowing problems (16/80, 89%), which kept them motivated to participate in the training sessions (9/18, 50%). Conclusions:The Rephagia biofeedback system for stimulating swallowing actions in tracheotomized ICU patients with dysphagia is feasible. No relation was found between clinical improvement in swallowing function and sEMG signals.

Background: In patients with ARDS, positive end-expiratory pressure (PEEP) titration remains a challenge and recommendations are not in agreement. In mechanically ventilated patients with COVID-19, subphenotypes based on different respiratory trajectories have been identified, but their heterogeneity in response to PEEP/Fio2 strategy remains understudied. Research Question: Can these previously determined subphenotypes be detected early in the course of mechanical ventilation, and do these subphenotypes moderate the association between PEEP and Fio2 ventilation strategy and mortality? Study Design and Methods: Retrospective analysis of invasively ventilated patients with COVID-19. Patients were categorized into 2 treatment groups: high PEEP/low Fio2 strategy and low PEEP/high Fio2 strategy. To replicate previously described longitudinal respiratory subphenotypes, hereafter named the low-power or high-power subphenotype, a prediction model was created. The primary outcome was the interaction between PEEP/Fio2 strategy and subphenotype, with mortality as the dependent variable. Results: Of the 1,464 patients included in this analysis, 361 patients (25%) were allocated into the high PEEP/low Fio2 strategy and 1,103 patients (75%) were allocated into the low PEEP/high Fio2 strategy. A prediction model consisting of respiratory data of the first 2 days of invasive ventilation (area under the receiver operating characteristics curve, 0.88) assigned 908 patients (62%) to the low-power subphenotype and 556 patients (38%) to the high-power subphenotype. The high-power subphenotype was characterized by higher minute volume, mechanical power, ventilatory ratio, and driving pressure. The association between PEEP/Fio2 ventilation strategy and ICU mortality was moderated by the subphenotype (P = .03), with high PEEP/low Fio2 ventilation being associated with lower mortality in the low-power subphenotype (OR, 0.46; 95% CI, 0.31-0.67; P < .001) and not in the high-power subphenotype (OR, 0.85; 95% CI, 0.57-1.28; P = .44). Interpretation: In this study, high PEEP/low Fio2 ventilation was associated with improved mortality only in one of the subphenotypes, suggesting that such subphenotypes influence heterogeneity of PEEP and Fio2 effect and should be considered in personalized ventilation strategies. Clinical Trial Registry: ClinicalTrials.gov; No.: NCT05954351; URL: www.clinicaltrials.gov

Introduction and objectives Nil by mouth (NBM) is a frequent imposition for patients recovering from critical illness.Its impact on patients’ wellbeing and rehabilitation is under researched. We sought ICU multidisciplinary opinion to primarily assess the relevance of taste deprivation on patient care and recovery, and to identify future opportunities for innovation and research. Methodology A descriptive, multiformat, observational, online survey investigated the experiences of specialist multidisciplinary healthcare professionals (HCP) from two academic hospitals regarding working with NBM patients. An e-survey containing 16 multiformat questions was developed by an experienced multidisciplinary HCP team and distributed over a 3-month period in 2023. The CHERRIES guidelines were followed for reporting of results. Results 58 HCPs completed the study. 97% of HCPs reported witnessing patient discomfort or distress when NBM. 91% believed felt that it impacted negatively on patients’ engagement in their own recovery. 59% did not discuss food and taste with patients when prolonged NBM was anticipated because there was no solution on offer. 41% of HCPs did discuss flavour and food, to build rapport and help motivate recovery. 57% of HCPs often felt pressure to give oral food/liquid to a NBM patient. 90% of participants reported that a safe taste product could enhance a patient’s ICU experience. Concerns regarding safety and a need for guidelines to enable implementation were common. Conclusion HCPs recognise the psychological sequalae on the patient and the impact on their relationship with the patient, that taste deprivation creates in recovering critically ill patients. Safe alternatives to oral intake that can enhance the ICU experience are considered desirable; this needs further research and innovation. Furthermore, with training and support HCPs should feel empowered to discuss NBM associated distress and challenge NBM recommendations. Implications for clinical practice There is demand for safe alternatives to oral flavour intake and belief this could enhance the ICU experience with downstream positive impact on ICU morbidity.

BACKGROUND:Recovery interventions initiated in the intensive care unit (ICU) or after discharge are essential for supporting ICU survivors and their families. Despite national guidelines aimed at standardizing and improving post-ICU care, implementation varies due to systemic and operational barriers. AIM:This study evaluates the organization of post-ICU care in the Netherlands, assesses whether national guideline recommendations are appropriated in practice, and explores barriers to implementation from healthcare professionals' perspectives. METHODS:A nationwide cross-sectional study was conducted (November 2023- February 2024) across all Dutch hospitals with adult ICUs. A structured, telephone-administered questionnaire collected data on ICU characteristics, post-ICU care coordination, early and late recovery interventions, and implementation barriers. The data were compared with a similar 2018 study. RESULTS:All 72 ICUs (100 %) participated. While 97.2 % provided at least one early and one late post-ICU recovery intervention-such as ICU diaries (97.2 %), ward follow-ups (93.1 %), and aftercare consultations (93.1 %)- only 27.8 % reported appropriating the full range of the national guideline strategies. Reported barriers included limited time, staff shortages, and financial constraints. While overall post-ICU care provision remained stable compared to 2018, notable improvements were observed in protocol use, nurse involvement in ICU diaries, and family engagement. CONCLUSION:Despite the widespread post-ICU care provision, full appropriation of national guideline recommendations remains limited. Addressing practical barriers is essential for fostering consistent, high-quality post-ICU care. Targeted interventions are needed to bridge gaps and support equitable, patient-centered recovery pathways.

PURPOSE:To evaluate the effect of structured staff training on the respiratory support provided. MATERIALS AND METHODS:Staff training with emphasis on the applied DP in mechanical ventilation was provided during one year. After completion of staff training, the effect was prospectively evaluated in patients who were continuously mechanically ventilated in a controlled mode for at least 6 h starting from admission. Pressure difference (Pdiff = Ppeak - PEEPtot) in the baseline period, as a derivative of the driving pressure, was compared with two evaluation periods from 0 to 6 months and 6-12 months (i.e. follow-up) after completion of the training. RESULTS:At analysis 248 patients met the inclusion criteria. In the baseline period Pdiff was not lung protective (> 15 cm H2O) in 39% of cases. In the first follow-up period this decreased to 25% of cases and further dropped to 17% in the second follow-up period. This was a relative decrease of 56% compared to the training period. At the end of evaluation the proportion of patients with a safe Pdiff had gradually increased from 58% during training to 82% (χ2 = p 0.005). CONCLUSIONS:These results suggest that ICU staff training could lead to more adequate respiratory support provided during controlled mechanical ventilation.

OBJECTIVES:Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome set (Comm-COS) for future trials of communication interventions in this population. DESIGN:1) Systematic review, 2) patient/family interviews, 3) two-round modified Delphi, and 4) virtual consensus meetings with a final voting round. A multidisciplinary expert steering committee oversaw all stages. SETTING:Interviews and consensus meetings were conducted via videoconferencing. Digital methods were used for Delphi and final Comm-COS voting. SUBJECTS:Three stakeholder groups: 1) patient and family members with lived experience within 3 years, 2) clinicians with experience working in critical care, and 3) researchers publishing in the field. INTERVENTION:None. MEASUREMENTS AND MAIN RESULTS:We identified 59 outcomes via our systematic review, 3 unique outcomes from qualitative interviews, and 2 outcomes from our steering committee. Following item reduction, 32 outcomes were presented in Delphi round 1; 134 participants voted; 15 patient/family (11%), 91 clinicians (68%), and 28 researchers (21%). Nine additional outcomes were generated and added to round 2; 106 (81%) participants voted. Following completion of the consensus processes, the Comm-COS includes seven outcomes: 1) changes in emotions and wellbeing associated with ability to communicate, 2) physical impact of communication aid use, 3) time to functional communication, 4) ability to communicate healthcare needs (comfort/care/safety/decisions), 5) conversation agency, 6) ability to establish a communication connection to develop and maintain relationships, and 7) acceptability of the communication intervention. CONCLUSIONS:This is the first COS to specifically focus on communication for critically ill adults. Limitations for operationalization include selection of measures to use with these outcomes. Identification of suitable measures and adoption of the Comm-COS in future trials will help establish effective interventions to ameliorate the highly prevalent and negative experience of communicative incapacity.

Purpose: Low-molecular-weight heparins (LMWHs) are widely used for prevention and treatment of venous thromboembolism (VTE) in critically ill patients. The objective of this study was to assess the dose-response relationship between nadroparin dose and anti-Xa activity in ICU patients. Materials and methods: Critically ill adult patients who were admitted to the ICU, and received at least three subcutaneous injections of nadroparin were included. The dose-effect relationship between nadroparin dose and anti-Xa level was analysed through a mixed-effects logistic regression model. Results: In total, 327 ICU patients were included. Median anti-Xa levels ranged from <0.1 IU/mL after nadroparin 0-37 IU/kg/day to 0.6 IU/mL after nadroparin >85 IU/kg/day (p < 0.01). Among all 1520 anti-Xa measurements, 859 (57 %) measurements were in the desired anti-Xa range. The best adequacy of anti-Xa levels was observed in nadroparin doses of 38-85 IU/kg (73 %). No differences in the odds of bleeding events or VTE between different anti-Xa levels were found. Conclusions: We found a clear dose-response relationship between nadroparin dose and anti-Xa levels. Increasing nadroparin doses led to more adequate anti-Xa levels without a change in the occurrence of VTE or major bleeding events, suggesting that LMWH therapy can be successfully and safely personalized using anti-Xa guided dosing.

Rationale: The positive end-expiratory pressure (PEEP) strategy in patients with coronavirus 2019 (COVID-19) acute respiratory distress syndrome (ARDS) remains debated. Most studies originate from the initial waves of the pandemic. Here we aimed to assess the impact of high PEEP/low FiO2 ventilation on outcomes during the second wave in the Netherlands. Methods: Retrospective observational study of invasively ventilated COVID-19 patients during the second wave. Patients were categorized based on whether they received high PEEP or low PEEP ventilation according to the ARDS Network tables. The primary outcome was ICU mortality, and secondary outcomes included hospital and 90-day mortality, duration of ventilation and length of stay, and the occurrence of kidney injury. Propensity matching was performed to correct for factors with a known relationship to ICU mortality. Results: This analysis included 790 COVID-ARDS patients. At ICU discharge, 32 (22.5%) out of 142 high PEEP patients and 254 (39.2%) out of 848 low PEEP patients had died (HR 0.66 [0.46-0.96]; P = 0.03). High PEEP was linked to improved secondary outcomes. Matched analysis did not change findings. Conclusions: High PEEP ventilation was associated with improved ICU survival in patients with COVID-ARDS.

"The Challenges of Using and Measuring Thiamine in Critical Care." American Journal of Respiratory and Critical Care Medicine, 0(ja), pp.

Background Drug-drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high -risk drug combinations. Methods We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high -risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high -risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. Findings In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high -risk drug combinations per 1000 drug administrations per patient was 26 center dot 2 (SD 53 center dot 4) in the intervention group (n=5534), compared with 35 center dot 6 (65 center dot 0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5-18%; p=0 center dot 0008) in the number of administered high -risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. Interpretation This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high -risk drug combinations. Our list of high -risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings.

OBJECTIVES:This study aimed to provide new insights into the impact of emergency department (ED) to ICU time on hospital mortality, stratifying patients by academic and nonacademic teaching (NACT) hospitals, and considering Acute Physiology and Chronic Health Evaluation (APACHE)-IV probability and ED-triage scores. DESIGN, SETTING, AND PATIENTS:We conducted a retrospective cohort study (2009-2020) using data from the Dutch National Intensive Care Evaluation registry. Patients directly admitted from the ED to the ICU were included from four academic and eight NACT hospitals. Odds ratios (ORs) for mortality associated with ED-to-ICU time were estimated using multivariable regression, both crude and after adjusting for and stratifying by APACHE-IV probability and ED-triage scores. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:A total of 28,455 patients were included. The median ED-to-ICU time was 1.9 hours (interquartile range, 1.2-3.1 hr). No overall association was observed between ED-to-ICU time and hospital mortality after adjusting for APACHE-IV probability ( p = 0.36). For patients with an APACHE-IV probability greater than 55.4% (highest quintile) and an ED-to-ICU time greater than 3.4 hours the adjusted OR (ORs adjApache ) was 1.24 (95% CI, 1.00-1.54; p < 0.05) as compared with the reference category (< 1.1 hr). In the academic hospitals, the ORs adjApache for ED-to-ICU times of 1.6-2.3, 2.3-3.4, and greater than 3.4 hours were 1.21 (1.01-1.46), 1.21 (1.00-1.46), and 1.34 (1.10-1.64), respectively. In NACT hospitals, no association was observed ( p = 0.07). Subsequently, ORs were adjusted for ED-triage score (ORs adjED ). In the academic hospitals the ORs adjED for ED-to-ICU times greater than 3.4 hours was 0.98 (0.81-1.19), no overall association was observed ( p = 0.08). In NACT hospitals, all time-ascending quintiles had ORs adjED values of less than 1.0 ( p < 0.01). CONCLUSIONS:In patients with the highest APACHE-IV probability at academic hospitals, a prolonged ED-to-ICU time was associated with increased hospital mortality. We found no significant or consistent unfavorable association in lower APACHE-IV probability groups and NACT hospitals. The association between longer ED-to-ICU time and higher mortality was not found after adjustment and stratification for ED-triage score.