ICU

An increasing number of invasive infections due to multidrug-resistant Candida species have been reported worldwide. Among these Candida species, Candida auris has attracted more attention in recent years due to major outbreaks in healthcare facilities globally and is considered an emerging pathogen. This study was planned to observe the occurrence of C. auris infections in a tertiary care hospital in India.

The clinical specimens were inoculated on Sabouraud dextrose agar along with other conventional culture media for aerobic culture based on specimen type. The blood culture was performed by BacT/ALERT 3D automated blood culture system. After preliminary identification, the species-level identification of Candida was performed by the VITEK-2 compact automated system from bioMerieux, France.

Out of a total of 497 Candida isolates, 21.33% were Candida albicans, while 78.67% were non-albicans Candida species. Candida auris comprised 3.22% of all Candida isolates. Among various risk factors, intensive care unit stay was the most common risk factor associated with C. auris infection. The antifungal susceptibility data highlighted the resistance of C. auris against most of the antifungals except echinocandins.

Infections due to C. auris are emerging in hospital environments, especially among individuals having various risk factors. The resistant nature of C. auris further complicates the situation leading to frequent antifungal treatment failure.

Carbapenem-resistant Klebsiella pneumoniae (CRKP) is increasingly recognized as a significant global public health threat. However, comprehensive long-term epidemiological surveillance of clinical CRKP isolates in China (Lishui city) remains limited.

To address this gap, we conducted a retrospective observational study spanning 2015 to 2024, aiming to evaluate the prevalence, drug resistance genes, and evolution of clinical CRKP isolates.

Clinical data and drug resistance profiles of CRKP isolates from hospitalized patients were retrieved from medical records. Antibiotic resistance genes were analyzed using whole-genome sequencing. Fourier-transform infrared spectroscopy (FTIR) was employed to examine the genetic evolution of the bacteria.

A total of 6 676 K. pneumoniae strains were detected, including 714 CRKP strains. The detection rate of CRKP fluctuated from 9.77% in 2015 to a low of 3.00% in 2016, then increased to 10.38% in 2024. Clinical risk factors for CRKP included intensive care unit (ICU) admission, hospitalization, and age over 60 years. All 25 CRKP strains were identified as ST11 type and carried bla KPC-2 and bla SHV enzyme genes. The FTIR typing revealed that the predominant circulating strains from 2020 to 2024 belonged to the same clone.

The detection rate of CRKP in our hospital has shown an increasing trend over the past decade. The bla KPC-2 gene is the predominant drug resistance determinant in CRKP, and horizontal transmission of the same clone is evident.

Early diagnosis of patients in the ICU can significantly contribute to improved quality of care. This study aims to compare the diagnostic accuracy of Confusion Assessment Method for the ICU (CAM-ICU) and Nursing Evaluation and Education of Cognitive Health Assessment Model (NEECHAM) Confusion Scale tools with DSM-IV diagnostic criteria for patients who have undergone coronary artery bypass surgery (CABG).

In this cross-sectional study, 280 patients were examined. Delirium assessments were conducted a day after surgery. The evaluation process involved the following steps: An intensive care specialist assessed the patients’ delirium status according to the DSM-IV criteria (as the reference standard). Subsequently, the researcher evaluated the same patients using the NEECHAM tool. Finally, the researcher assessed the patients using the CAM-ICU tool. Thereafter, sensitivity, specificity, positive and negative predictive values, and Kappa agreement coefficient were measured to compare the diagnostic accuracy of both CAM-ICU and NEECHAM tools with DSM-IV.

The frequency of delirium varied depending on the diagnostic tool used: DSM-IV: 12%; CAM-ICU: 2.9%; and NEECHAM: 3.9%. The sensitivity and specificity values for each tool were as follows:CAM-ICU: sensitivity: 25% (95% CI, 11.5% to 43.4%) and specificity: 98.5%. NEECHAM: sensitivity: 34.4%, 95% CI, 18.6% to 53.2%) and specificity: 98.5%. Both CAM-ICU and NEECHAM demonstrated a positive predictive value of 100%. The negative predictive values were 91.1% for CAM-ICU and 92.1% for NEECHAM. The Kappa coefficient was calculated to be 0.73.

There was no significant difference between the diagnostic accuracy of NEECHAM and the CAM-ICU tools in detecting delirium. Both tools demonstrated low sensitivity but high specificity in diagnosing delirium following CABG.

Pain is a persistent concern and a common symptom in critically ill patients. It is an increasingly unpleasant experience in patients discharged from the intensive care units (ICUs). 

This study aims to evaluate the correlation of pain intensity with the acute physiology and chronic health evaluation (APACHE II) score, the Ramsay sedation scale (RSS) score, and some ventilation parameters in patients under mechanical ventilation admitted to the ICU. 

This cross-sectional study was conducted on 40 intubated patients under mechanical ventilation at the trauma ICU of a hospital in Sabzevar, Iran, from November 2020 to May 2021. The samples were selected using a convenience sampling method. Data were collected using the critical-care pain observation tool (CPOT), APACHE II, RSS, and a form surveying demographic and ventilation parameters. Data analysis was performed using descriptive statistics, Spearman’s correlation test, and Mann-Whitney U test. The significance level was set at 0.05.

Among participants, 87.5% were male (n=35) and 12.5% female (n=5). Their mean age was 42.80±17.12 years, ranged 18-83 years. The CPOT score at rest (r=0.78) and during suctioning (r=0.72) was significantly correlated with the APACHE II score (P=0.001). It also had a significant association with the RSS score at rest and during suctioning and position change (P=0.001), surgical diagnosis (P=0.002 at rest, P=0.001 during suctioning), and using sedatives (P=0.001 at rest, P=0.001 during procedure). However, no significant correlation was observed between the CPOT score and ventilation parameters. Pain intensity was significantly different among patients with and without a history of addiction (r=0.68, P=0.015 at rest; P=0.002 during suctioning).

Given the correlation of the pain intensity with the APACHE II and RSS scores in patients under mechanical ventilation, these factors should be considered by healthcare planners to promote the quality of care and effective management of pain in these patients admitted to ICUs.

As an epidemic, COVID‑19 has brought a new shock to the world’s healthcare system. The crisis caused by this disease and the prolonged involvement of communities and healthcare systems have intensified the duties and psychological burden of nurses. The current study aimed to explain the experience of ICU nurses during the COVID‑19 crisis.

The present study was conducted using conventional content analysis in 2021. Twenty nurses of the COVID‑19 ICU of Ahvaz hospitals were selected by purposive sampling. The main method of data collection was semistructured interview. The process of data analysis was done based on Granheim and Lundman’s approach using MAXQDA‑2020. For the scientific rigor of the findings, Guba and Lincoln’s four criteria were abided by. The COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist was used to ensure the study met the recommended standards of qualitative data reporting.

After data analysis, 22 subcategories, eight categories, and one theme (growth under pressure) were extracted. The eight main categories included (psychological crisis, physical exhaustion, family conflicts, complex care, professional development, expertise, life enrichment, and full support).

Despite the pressures that ICU nurses faced during the COVID‑19 pandemic, they were able to grow by benefiting from positive experiences. These findings can lead to the development and implementation of effective interventions to improve adaptation strategies of nurses, especially those working in the intensive care unit, during the COVID‑19 and other future crises.

Healthcare-associated infections (HAIs) in intensive care unit (ICU) patients significantly complicate the normal hospitalization process and affect patients’ condition, length of hospitalization, mortality, and treatment cost. In this study, we aimed to determine the prevalence and economic burden of HAIs.

The study involved all patients with a confirmed HAIs (based on CDC/NHSN case-definitions); in the general ICU of a tertiary university hospital in Tehran, from April 2020 to March 2021. The patients’ information, including length of hospitalization, outcome, type and cost of prescribed antibiotics, were recorded.

During the study period, 119 HAIs were found in 1395 (43% F / 57% M) patients. The prevalence of nosocomial infections was 8.53%. The mean duration of hospitalization in all ICU patients was 4.7 ± 3.1 days, and 31.85 ± 18.96 days in patients with HAIs. The most common organisms involved in HAIs are Acinetobacter baumannii (54.6%), Klebsiella pneumoniae (30.3%), E. coli (15.1%), and Enterococcus spp. (12%). Incidence density of ventilator-associated pneumonia (VAP), central line-associated bloodstream infection (CLA-BSI), and catheter-associated urinary tract infection (CA-UTI) per 1000 device-days were 36.08, 17.57, and 8.86, respectively. The total cost of antibiotics for HAIs was € 105,407. Among these, the highest consumption costs were for carbapenems, followed by colistin and caspofungin.

This study showed the high burden of nosocomial infections in ICUs. Strategies for more strict infection prevention and control are necessary to reduce this burden.

Suctioning has been to date documented as one of the most painful and anxiety-inducing experiences among mechanically ventilated patients admitted to intensive care units.

The present study was conducted with aim to investigate the impact of foot reflexology, as a non-pharmacological method, on suctioning-induced anxiety in ICU patients receiving mechanical ventilation.

This randomized controlled trial study was conducted on 36 mechanically ventilated patients in the ICU of a military hospital in Tehran, Iran, in 2021. The subjects were randomized into either the intervention group (foot reflexology) or the control group (routine care). After the completion of the suctioning procedure, the foot reflexology technique was applied for 20 minutes on reflex points of the heart and lungs (the anterior third of the sole of the foot) in the intervention group patients. Levels of anxiety were assessed using the Faces Anxiety Scale (FAS) before and after the intervention.

No statistically significant difference was found between the two groups in demographic characteristics and anxiety levels at the pre-intervention stage. However, anxiety was significantly reduced after foot reflexology treatment in the intervention group compared to the controls (p<0.001). Additionally, anxiety levels significantly decreased in the intervention group after the intervention compared to before the intervention (p<0.001), while increased in the control group (p=0.001).

Implications for Practice: 

The results of the present study showed that foot reflexology is effective in reducing suctioning-induced in ICU patients receiving mechanical ventilation. Therefore, it is recommended to use this non-pharmacological approach at the patient's bedside.

The COVID-19 pandemic is considered a major health problem all over the world which has caused extensive and worldwide mortality and morbidities along with vast economic and political impact. Limitations of our knowledge and controversies in treatment modalities make the control and management of this disease more difficult. The status of electrolytes especially Mg and Zn in plasma and its correlation with the clinical situation and criteria for recovery has been investigated in various studies. Limited data in Iran mandate the design of a trial for evaluating our critically ill patients. We designed this study to investigate the correlation between plasma levels of Mg and Zn and the outcome including patients' need for assisted/ controlled ventilation, time required for weaning, length of ICU stay, and probable cause of death.
413 patients with severe respiratory signs of COVID-19 disease who were admitted to the ICUs of 3 medical centers of Shahid Beheshti University of Medical Sciences were evaluated for plasma levels of Mg and Zn. Supplemental therapy was introduced when needed and was followed until discharge from ICU or death. All recorded data were analyzed by statistical methods and results were compared with similar studies.
20.6% and 35.1% of all participants had low serum levels of Mg and Zn, respectively. 11 patients (2.7%) died through the treatment period. 56.9% and 61.0% of participants received Mg and Zn supplements, respectively.
According to our results, serum Mg and Zn levels did not show a significant correlation with the risk of death due to severe COVID-19 disease, prolonged assisted ventilation, or duration of ICU stay. There was no significant association between Mg and Zn supplementation with the risk of death due to severe COVID-19; however, it showed an inverse relationship with the time required for assisted ventilation and the duration of ICU stay. It seems that Mg and Zn supplementation can be useful in preventing or managing some of the morbidities among COVID-19 patients.

The role of caffeine as a brain stimulant in improving the respiratory characteristics of patients under mechanical ventilation is unclear. This study aimed at determining the effect of oral caffeine in helping to release (Liberation) from the ventilator in intubated patients under mechanical ventilation admitted to the intensive care unit.
General ICU patients with more than 48 hours of dependency on a ventilator were randomly divided into two groups. The intervention group received 200mg caffeine tablets twice a day through a gastric tube, while the control group received a placebo of the same amount. Every day, patients were assessed for the likelihood of being disconnected from the device. If their clinical condition was deemed suitable, the device mode was switched to spontaneous, and their Rapid Shallow Breathing Index (RSBI) was calculated. Based on this information, a decision was made regarding whether to proceed with weaning.
Caffeine use in ICU patients significantly reduced the airway resistance index of patients (P <0.05). However, although this drug reduced the length of hospital stay in the ICU and the duration of intubation of patients, these changes were not statistically significant (P> 0.05).
Caffeine may improve respiratory status and reduce the duration of intubation and hospitalization in the ICU.

Sleep is one of the basic physiological needs of human life. Hospitalization causes disturbances in the sleep pattern and decreases the quality of sleep. The present study aimed to compare the effect of Swedish massage and earplugs/eye masks on the quality of sleep of patients admitted to the intensive care units (ICUs) of the teaching hospitals affiliated with Zahedan University of Medical Sciences in Zahedan, Iran, in 2022.

This quasi-experimental study was conducted on 40 patients admitted to the ICUs of Khatam Al-Anbia and Ali Ibne Abi-Talib hospitals in Zahedan. The participants were selected through convenience sampling from the patients who met the inclusion criteria. By using the permuted block technique with colored cards (red and yellow), the patients were placed into two Swedish massage and earplug/eye mask groups. After enrollment in the study, the patients in both groups did not receive any intervention during the first night, and their sleep quality was checked using the Richards-Campbell Sleep Questionnaire (RCSQ) as a pre-test during the first night. The participants in both groups received the intended interventions on the second night after entering the study, and their sleep quality on the second night was measured as a post-test. The participants in the first intervention group received a Swedish massage one night for 20 minutes before bedtime in the back area (lumbar cavity to the shoulder). Moreover, the participants in the second intervention group were asked to wear earplugs and eye masks for one night from 10 p.m. to 6 a.m. The collected data were analyzed using independent samples t-test, paired samples t-test, and chi-square test with SPSS software (version 26).

The results showed that the mean sleep quality scores for the participants in the Swedish massage group and earplug/eye maskgroupwere 130.25 ± 41.91 and 135 ± 44.36 before the intervention, respectively. In addition, themeansleep quality scores for the participants in the Swedish massage group and earplug/eye mask group were 202 ± 46.03 and 184.79 ± 39.5 after the intervention, respectively, showing a significant increase in the sleep quality scores for the participants in both groups after the intervention (P = 0.001). In addition, the independent samples t-test confirmed that the mean sleep quality score for the participants in the Swedish massagegroupwassignificantly higher than that of the participants in the earplug/eyemaskgroupafter the intervention (P=0.037).

Non-pharmacological interventions, such as Swedish massage and wearing earplugs and eye masks, can have a significant effect on increasing the sleep quality of patients admitted to the ICU. The data in this study indicated that compared to the earplug/eye mask group intervention, Swedish massage had a greater effect on improving the sleep quality of the patients. Therefore, the Swedish massage technique, which does not cause sensory restrictions similar to those of earplugs/eyemasks, can be applied as an inexpensive intervention without any complications to improve patients’ sleep quality.

 Delirium is a common concern among elderly intensive care unit (ICU) patients. Ketamine’s effectiveness in preventing delirium remains controversial despite its demonstrated neuroprotective properties and cognitive benefits in previous studies.

 This study aimed to compare the safety and efficacy of ketamine and haloperidol in preventing delirium in elderly ICU patients.

 This randomized clinical trial involved 44 non-intubated patients aged over 65 years in a general ICU. The patients received low-dose intravenous ketamine (20 mg) or intramuscular haloperidol (2.5 mg). Delirium was assessed using the Richmond Agitation Sedation Scale (RASS) at 5, 10, and 15 minutes. The primary outcome was the percentage of patients achieving adequate sedation (RASS ≤ +1). The secondary outcome was time to reach adequate sedation. Adverse effects and physician satisfaction were evaluated after 60 minutes.

 No significant difference in delirium was observed between the groups after interventions or within each group over time. However, the ketamine group had significantly lower delirium incidence at 5 minutes. The percentage of patients achieving adequate sedation was higher in the ketamine group (86.4%) than in the haloperidol group (36.4%) (P = 0.002). There was a delirium difference between groups at 10 minutes (P = 0.31) or 15 minutes (P = 0.082). Physician satisfaction did not differ significantly (P = 0.144).

 The present study suggests that the administration of low-dose ketamine to elderly ICU patients might reduce delirium incidence, supporting its beneficial effect for delirium control.

This study aimed to determine the AKI prevalence and the contributing factors among trauma patients admitted to the ICU of the only level-one trauma center in south Iran.
The present study was a retrospective cohort of patients with post-traumatic AKI admitted to the intensive care units of Shahid Rajaee (Emtiaz) Trauma Hospital in Shiraz, Iran, between March 21, 2021, and February 20, 2022. The variables were obtained from the Iran Intensive Care Unit Registry program (IICUR). Demographic features (age, sex, height, weight), vital signs including heart rate, respiratory rate, temperature, blood pressure, outcome, and laboratory findings were gathered.
In total, 2271 trauma patients admitted to the ICUs were included in 398 cases (17.5%) developed with AKI. Most AKI patients, 249 (62.60%) were in stage 1 disease. Of 77(19.30%) individuals in stage 2, 72(18.10%) were in stage 3 of the disease. Most AKI patients were male, with a mean age of 52.92± 22.06 years. AKI patients were hospitalized in the intensive care unit for significantly more days than patients without AKI and were more severe regarding APACHE II and GCS (p-value <0.001).
Acute renal injury in ICU trauma patients is a common complication with significant mortality and length of hospital stay. Age, high APACHE II score, minimum systolic blood pressure, acute renal injury, and low GCS score are strong risk factors associated with mortality in intensive care unit patients. Patients with acute kidney injury are five times more likely to die.

Nosocomial infections have increased among patients admitted to the intensive care unit (ICU).

This study investigated the microbiota pattern of the respiratory system in hospitalized patients with treatment-resistant respiratory infections compared to those without treatment-resistant respiratory infections.

This case-control study utilized sputum samples from hospital-acquired infection (HAI) and non-HAI (NHAI) patients over 52 years old hospitalized in the ICU. Identification and determination of the drug sensitivity of the bacteria responsible for treatment-resistant respiratory infections were made by culture method in selective and differential media and VITEK 2 device. Finally, quantitative polymerase chain reaction (qPCR) was used to analyze the microbiota of the respiratory system.

Excessive prescription of antibiotics, long hospitalization, and history of surgery were important risk factors for nosocomial infections. The study of antibiotic resistance of pathogens causing hospital infections indicated their high resistance to most common antibiotics. Also, nosocomial infections led to a change in lung microbiota in HAI patients. The frequencies of Streptococcus pyogenes, S. pneumoniae, and Haemophilus influenzae were higher in patients with treatment-resistant respiratory infection (P < 0.05), but the frequency of Neisseria spp. was higher in patients without treatment-resistant respiratory infection (P < 0.05).

The pathogens responsible for nosocomial infections had acquired resistance to a wide range of antibiotics, leading to changes in their respiratory microbiota. 

 Vitamin D has neuroprotective and anti-inflammatory effects in stroke patients, but its effect on pro-inflammatory and inflammatory cytokines, especially IL-1, has been investigated in a few trials.

 This study aimed to determine the effect of prescribing a high dose of vitamin D on the anti-inflammatory parameters, short-term and long-term prognosis of patients with ischemic stroke.

 This randomized clinical trial was performed on 42 patients randomly divided into two equal groups of 21 in Imam Hussein Hospital. The patients were allocated through block randomization methods to receive 300,000 units of vitamin D (intramuscularly) or not receive it as a control group. Age, gender, and clinical and laboratory information were recorded. The stroke severity was calculated according to the National Institute of Health Stroke Scale (NIHSS) at the beginning of hospitalization and upon hospital discharge. The 3-month prognosis of the patients was recorded according to the Barthel criteria three months after the stroke. Vitamin D3 levels were recorded before and after injection, while the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were assessed on the first day and for 7 consecutive days after hospitalization. All statistical analyses were performed using STATA version 14. A P-value < 0.05 was considered significant.

 The mean age of the patients was 61.45 ± 4.74 years. There were 18 female (42.86%) and 24 male patients (57.14%). In the vitamin D group, the mean IL-1 decreased compared to before the intervention (-23.60 ± 103.83), but this decrease was not statistically significant (P = 0.070). In addition, the changes in IL-1 after the intervention were statistically different between the two groups (mean difference of -23.60 ± 103.83 in the vitamin D group vs. 15.96 ± 9.64 in the control group). The mean IL-6 decreased in both groups after the intervention compared to before, although these changes were not statistically significant (P > 0.05). In the group receiving vitamin D compared to the control group, the mean NLR decreased by about 2 units, the PLR decreased by about 10 units, and the NIHSS score decreased by about one unit during the study. However, these changes were not statistically significant (P > 0.05).

 A high dose of vitamin D can improve the NIHSS score and decrease IL-1 and IL-6, although these changes were not statistically significant. The mean NLR and PLR decreased after using high-dose vitamin D.

 The proper decision-making on weaning patients from the ventilator, removing the endotracheal tube, reducing complications, and the way of cooperating between doctor and nurse is always one of the concerns of intensive care unit (ICU) nurses.

 This study aimed to determine the effect of clinical decision-making based on interactive education on the successful extubations of patients in the ICU.

 This quasi-experimental study was conducted on 50 nurses in the ICU of Ganjavian Hospital in Dezful, Iran, within August-December 2021. The nurses were selected based on inclusion criteria and randomly assigned into intervention and control groups. Clinical decision-making training regarding extubation was provided interactively for one month in five sessions in the experimental group. The data were obtained using a demographic information questionnaire, the Clinical Decision-Making Questionnaire by Lauri et al., and extubation checklist and analyzed using SPSS software (version 24) using descriptive and inferential statistics (i.e., chi-square test, covariance, independent t-test, and paired t-test).

 No difference was observed between the two groups in terms of demographic information (P < 0.05). After the intervention, the mean score of nurses’ clinical decisions and the number of successful extubations in the experimental group were higher than in the control group, with a statistically significant difference (P = 0.014).

 Interactive training effectively improves decision-making skills concerning successful extubations. Therefore, it is suggested to use this method in educational programs to improve the clinical decision-making of nurses, students, and nursing managers.