Summary: Background & Aims: Nutrition therapy is a critical component of care for critically ill patients in the intensive care unit (ICU). Caloric intake can be provided by artificial nutrition and also by some treatments providing non-nutritional calories (NNCs). The aim of this study was to assess the contribution of NNCs from propofol and dextrose infusions to daily caloric intake. Methods: A retrospective observational study was carried out in three ICUs of a university hospital. Mechanically ventilated patients admitted to ICU for acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19) were included. Daily caloric intake, including NNCs from propofol and dextrose infusions, and calories from artificial nutrition was assessed over the initial seven days of ICU admission. Results: A total of 157 patients were included in the analysis. During the early phase of ICU admission, NNCs constituted all the proportion of caloric intake (Day 1: 100% [100–100], Day 2: 100% [100–100], Day 3: 100% [63–100]). This dominance gradually decreased with the introduction of artificial nutrition after a median of 4 days [3–5]. Propofol contributed significantly to NNCs, constituting a median of 26.6% [15.5–54.0] of total daily caloric intake and 66.2% [53.0–76.4] of daily NNCs intake in patients receiving propofol. By Day 7, only 47.3% of patients had reached their caloric target, while 45.8% remained below target and 6.9% were above target. The instances of overnutrition were minimal and were often associated with NNCs, particularly propofol. Mortality at Day 28 in patients who received propofol during the first 7 days was 32/117 (27%) versus 23/40 (57%) in those who did not (P < 0.001). Conclusions: Our study emphasizes the significant role of NNCs in the early nutritional intake of ICU patients suffering from ARDS due to COVID-19. These findings highlight the need for careful nutritional management in these patients, with particular consideration given to NNCs. Future research should investigate strategies to optimize nutritional support in this specific population.

Background Given the pathophysiology of hypoxemia in patients with Covid-19 acute respiratory failure (ARF), it seemed necessary to evaluate whether ROX index (ratio SpO 2 /FiO 2 to respiratory rate) could accurately predict intubation or death in these patients initially treated by high-flow nasal oxygenation (HFNO). We aimed, therefore, to assess the accuracy of ROX index to discriminate between HFNO failure (sensitivity) and HFNO success (specificity). Methods We designed a multicentre retrospective cohort study including consecutive patients with Covid-19 ARF. In addition to its accuracy, we assessed the usefulness of ROX index to predict HFNO failure (intubation or death) via logistic regression. Results Among 218 ARF patients screened, 99 were first treated with HFNO, including 49 HFNO failures (46 intubations, 3 deaths before intubation). At HFNO initiation (H0), ROX index sensitivity was 63% (95%CI 48–77%) and specificity 76% (95%CI 62–87%) using Youden’s index. With 4.88 as ROX index cut-off at H12, sensitivity was 29% (95%CI 14–48%) and specificity 90% (95%CI 78–97%). Youden’s index yielded 8.73 as ROX index cut-off at H12, with 87% sensitivity (95%CI 70–96%) and 45% specificity (95%CI 31–60%). ROX index at H0 was associated with HFNO failure ( p = 0.0005) in univariate analysis. Multivariate analysis showed that SAPS II ( p = 0.0003) and radiographic extension of pulmonary injuries ( p = 0.0263), rather than ROX index, were predictive of HFNO failure. Conclusions ROX index cut-off values seem population-specific and the ROX index appears to have a technically acceptable but clinically low capability to discriminate between HFNO failures and successes in Covid-19 ARF patients. In addition, SAPS II and pulmonary injuries at ICU admission appear more useful than ROX index to predict the risk of intubation.

The current gold-standard treatment for COVID-19-related hypoxemic respiratory failure is invasive mechanical ventilation. However, do not intubate orders (DNI), prevent the use of this treatment in some cases. The aim of this study was to evaluate if non-invasive ventilatory supports can provide a good therapeutic alternative to invasive ventilation in patients with severe COVID-19 infection and a DNI. Data were collected from four centres in three European countries. Patients with severe COVID-19 infection were included. We emulated a hypothetical target trial in which outcomes were compared in patients with a DNI order treated exclusively by non-invasive respiratory support with patients who could be intubated if necessary. We set up a propensity score and an inverse probability of treatment weighting to remove confounding by indication. Four-hundred patients were included: 270 were eligible for intubation and 130 had a DNI order. The adjusted risk ratio for death among patients eligible for intubation was 0.81 (95% CI 0.46 to 1.42). The median length of stay in acute care for survivors was similar between groups (18 (10–31) vs. (19 (13–23.5); p = 0.76). The use of non-invasive respiratory support is a good compromise for patients with severe COVID-19 and a do not intubate order.

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

BACKGROUND The implementation of computerized monitoring and prescription systems in intensive care has proven to be reliable in reducing the rate of medical error and increasing patient care time. They also showed a benefit in reducing the length of stay in the intensive care unit (ICU). However, this benefit has been poorly studied, with conflicting results. OBJECTIVE This study aimed to show the impact of computerization on the length of stay in ICUs. METHODS This was a before-after retrospective observational study. All patients admitted in the surgical ICU at the Rouen University Hospital were included, from June 1, 2015, to June 1, 2016, for the before period and from August 1, 2016, to August 1, 2017, for the after period. The data were extracted from the hospitalization report and included the following: epidemiological data (age, sex, weight, height, and body mass index), reason for ICU admission, severity score at admission, length of stay and mortality in ICU, mortality in hospital, use of life support during the stay, and ICU readmission during the same hospital stay. The consumption of antibiotics, biological analyses, and the number of chest x-rays during the stay were also analyzed. RESULTS A total of 1600 patients were included: 839 in the before period and 761 in the after period. Only the severity score Simplified Acute Physiology Score II was significantly higher in the postcomputerization period (38 [SD 20] vs 40 [SD 21]; P<.05). There was no significant difference in terms of length of stay in ICU, mortality, or readmission during the stay. There was a significant increase in the volume of prescribed biological analyses (5416 [5192-5956] biological exams prescribed in the period before Intellispace Critical Care and Anesthesia [ICCA] vs 6374 [6013-6986] biological exams prescribed in the period after ICCA; P=.002), with an increase in the total cost of biological analyses, to the detriment of hematological and biochemical blood tests. There was also a trend toward reduction in the average number of chest x-rays, but this was not significant (0.55 [SD 0.39] chest x-rays per day per patient before computerization vs 0.51 [SD 0.37] chest x-rays per day per patient after computerization; P=.05). On the other hand, there was a decrease in antibiotic prescribing in terms of cost per patient after the implementation of computerization (€149.50 [$164 USD] per patient before computerization vs €105.40 [$155 USD] per patient after computerization). CONCLUSIONS Implementation of an intensive care information system at the Rouen University Hospital in June 2016 did not have an impact on reducing the length of stay.

Background: Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection. Objectives: The objective was to explore the impact of MaxZero (TM) connectors (BD; Franklin Lakes, US) on CRI in ICU. Methods: Observational, preepost design study (2011-2013 and 2014-2016) conducted in the surgical ICU of a tertiary care hospital (18 beds). Patients with a central venous catheter and a length of stay >48 h were included. The connectors replaced all disposable caps used on infusion stopcocks and ramps. The primary parameter was to compare the incidence of CRI between the "before" period and the "after" period. Results: A total of 1633 patients were included (789 "before" and 844 "after"). There was no difference between groups concerning the global duration of catheterisation (12.5 +/- 11.5 days vs. 12.1 +/- 10.9 days). There were 61 CRIs before and 28 CRIs after the introduction of connectors; the incidence of CRI in the "before" group was 20.33 CRI/year (6.18 CRI per 1000 catheter-days) vs. 9.33 CRI/year (2.73 CRI per 1000 catheter-days) in the "after" group (incidence rate ratio = 0.44; 95% confidence interval = 0.28-0.68, p < 0.001). However, after a global analysis of the 6-year period, when adjusting for seasonal effect and pre-existing linear trend, the effect was no longer significant (adjusted incidence rate ratio = 0.57; 95% confidence interval = 0.24-1.35, p = 0.20). Conclusions: Our results do not allow us to conclude to a potential beneficial effect of MaxZero (TM) on CRI but are compatible with its prolonged and safe use in ICU. Only future prospective works will be able to confirm the value of these connectors for CRI prevention. (c) 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

National guidelines recommend oral vancomycin for severe Clostridium difficile infection (CDI) based on results from recent clinical trials demonstrating improved clinical outcomes. However, real-world data to support these clinical trials are scant.To compare treatment patterns and patient outcomes of those treated for CDI before and after implementation of a severity-based CDI treatment policy at a tertiary teaching hospital.This study evaluated adult patients with a positive C. difficile toxin before and after implementation of a policy where patients with severe CDI given metronidazole were switched to oral vancomycin unless contra-indicated. Patients were stratified according to disease severity using a modified published severity score. Treatment patterns based on CDI severity and rates of refractory CDI were assessed.In total, 256 patients with CDI (mean age 66 years, standard deviation 17, 52% female) were evaluated (before implementation: N = 144; after implementation: N = 112). Use of oral vancomycin for severe CDI increased significantly from 14% (N = 8) to 91% (N = 48) following implementation of the policy (P < 0.0001). Refractory disease in patients with severe CDI decreased significantly from 37% to 15% following implementation of the policy (P = 0.035). No significant differences were noted among patients with mild to moderate CDI.A severity-based CDI treatment policy at a tertiary teaching hospital increased the use of oral vancomycin and was associated with decreased rates of refractory CDI.

Brunelle, Julie MD; Guigueno, Sandra MD; Gouin, Philippe MD; Tamion, Fabienne MD, PhD; Thibaut, Florence MD, PhD Author Information

Excavations at sites of the Harappan Civilization have yielded thousands of small artifacts, the former uses of which are often enigmatic. The function of one of these, the « terracotta spoon », is discussed here. Based on careful examination for use wear and consideration of manufacturing technique and morphology, it seems likely that this implement was usually employed with a palm wood handle and that at least one of its uses was to scrape foodstuffs from ceramic containers.