Journal of Intensive Care Medicine最新文献

{"title":"Phenobarbital Addition to Alcohol Withdrawal Treatment Offers Better Outcomes than Dexmedetomidine in Hospitalized Patients.","authors":"Mary Matecki, Ahmed Noureldin, Riad Akkari, Zachary Cohen, Matthew McMullan, Katrina Hawkins, Jeffrey Williams, Azuka Nwude, David Yamane, Babak Sarani, Sean M Lee, Susan Kartiko","doi":"10.1177/08850666251328881","DOIUrl":"10.1177/08850666251328881","url":null,"abstract":"<p><p>BackgroundThis study directly compares outcomes of phenobarbital and dexmedetomidine as adjuncts to symptom-triggered benzodiazepine treatment for alcohol withdrawal syndrome (AWS).MethodsThis is a retrospective cohort analysis at a single tertiary referral institution in a major urban center in the United States. In hospitalized patients above 18 years with AWS between May 1, 2018, and July 31, 2021 we compared the hospital length of stay (LOS), ICU LOS, mechanical ventilation incidence and duration of patients who received dexmedetomidine versus phenobarbital as adjuncts to lorazepam-based treatment. Patients were divided into two cohorts based on treatment they received - dexmedetomidine/lorazepam (DEX) versus phenobarbital/lorazepam (PHENO). The use of phenobarbital or dexmedetomidine was left to the discretion of the treating bedside physician.ResultsOne hundred fifty-six patients met inclusion criteria with 102 patients (65%) in the DEX group and 54 patients (35%) in the PHENO group. The PHENO group had a lower probability of intubation (OR 0.33, 95% CI 0.15-0.70, p = 0.005) and shorter hospital LOS (IRR 0.45, 95% CI 0.31-0.64, p < 0.001), and ICU LOS (IRR 0.58, 95% CI 0.34-1.00, p = 0.050). For both hospital and ICU LOS, the PHENO group had shorter LOS than dexmedetomidine at lower doses of lorazepam (<3 mg), but this protective effect diminished at higher doses of lorazepam, at a rate of 10% (hospital LOS, IRR 1.10, 95% CI 1.05-1.16, p < 0.001) and 6% (ICU LOS, IRR 1.06, 95% CI 0.99-1.13, p = 0.074) per milligram increase in lorazepam.ConclusionsA symptom- triggered lorazepam regimen including early phenobarbital administration for severe alcohol withdrawal syndrome is associated with lower hospital LOS and need for intubation compared to a symptom triggered lorazepam regimen with dexmedetomidine adjunct.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"948-955"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143729965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Identification of Risk Factors and Development of Prediction Models for Glasgow Coma Scale Score Deterioration in Stroke Patients: A Study Based on the MIMIC-IV Database.","authors":"Xuehui Fan, Jing Xu, Ruixue Ye, Jingpu Zhao, Yulong Wang","doi":"10.1177/08850666251325788","DOIUrl":"10.1177/08850666251325788","url":null,"abstract":"<p><p>ObjectiveStroke remains a major cause of mortality and disability worldwide. This study aims to identify the risk factors associated with Glasgow Coma Scale (GCS) deterioration in stroke patients using data from the MIMIC-IV database.MethodsWe conducted a retrospective cohort study based on the MIMIC-IV database, involving 1984 adult stroke patients. The main exposure variables included age, Charlson Comorbidity Index (CCI), and Sequential Organ Failure Assessment (SOFA) score. The outcome variable was GCS deterioration during hospitalization. Covariates included demographic information, comorbidities, and laboratory indicators. Multivariate logistic regression models were used to analyze risk factors.ResultsEach 1-point increase in SOFA score was associated with a 50.69% increased risk of GCS score deterioration (OR = 1.5069, 95% CI: 1.2641-1.7964, <i>P</i> < .0001). Each year increase in age was associated with a 24.19% increased risk (OR = 1.2419, 95% CI: 1.0496-1.4695, <i>P</i> = .0116). Each 1 mEq/L increase in minimum anion gap was associated with a 24.56% increased risk (OR = 1.2456, 95% CI: 1.0076-1.5398, <i>P</i> = .0424). Risk factors varied significantly among disease subtypes.ConclusionSOFA score, age, and anion gap are important predictors of GCS score deterioration in patients with neurological diseases. These findings may help identify high-risk patients early and optimize treatment strategies.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"937-947"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144326019","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Venoarterial Extracorporeal Membrane Oxygenation Therapy in Patients with Sickle Cell Disease: Case Series and Review for Intensive Care Physicians.","authors":"Alison Grazioli, Joseph Rabin, Raymond P Rector, Zhongjun J Wu, Allen P Burke, Nima Sharifai, Aakash Shah, Bradley S Taylor, Mark T Gladwin","doi":"10.1177/08850666241260605","DOIUrl":"10.1177/08850666241260605","url":null,"abstract":"<p><p>Sickle cell disease (SCD) is associated with substantial morbidity and early mortality in afflicted adults. Cardiopulmonary complications that occur at increased frequency in SCD such as pulmonary embolism, pulmonary arterial hypertension, and acute chest syndrome can acutely worsen right ventricular function and lead to cardiogenic shock. Mechanical circulatory support including venoarterial extracorporeal membrane oxygenation (VA ECMO) is being increasingly utilized to treat hemodynamic collapse in various patient populations. However, a paucity of literature exists to guide the use of mechanical circulatory support in adults with SCD where disease-related sequela and unique hematologic aspects of this disorder may complicate extracorporeal therapy and must be understood. Here, we review the literature and describe three cases of adult patients with SCD who developed cardiogenic shock from acute decompensated right heart failure and were treated clinically with VA ECMO. Using an in vitro ECMO system, we investigate a potential increased risk of systemic fat emboli in patients with SCD who may be experiencing vaso-occlusive events with bone marrow involvement given the high-volume shunting of blood from venous to arterial systems with VA ECMO. The purpose of this study is to describe available extracorporeal life support experiences, review potential complications, and discuss the special considerations needed to further our understanding of the utility of VA ECMO in those with SCD.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"929-936"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12265929/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141975887","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Relationship Between the Type of Microorganisms Isolated in Cultures and Outcomes in Children on Extracorporeal Membrane Oxygenation Support Following Corrective Surgery for Congenital Heart Disease.","authors":"Mónica Arias-Andrade, Carlos Miguel Santacruz, Martha Cecilia Reyes Casas, Juan Sebastián Barajas, Marco Fidel Sierra-Zuñiga, Catalina Duque, Martha I Àlvarez-Olmos, Nestor Sandoval, Jaime Fernández-Sarmiento","doi":"10.1177/08850666251327995","DOIUrl":"10.1177/08850666251327995","url":null,"abstract":"<p><p>ObjetivesExtracorporeal membrane oxygenation (ECMO) after surgery for congenital heart disease (CHD) provides hemodynamic support to patients when their myocardial function is temporarily affected. Postoperative infections in children with CHD on ECMO are a significant challenge, as they complicate recovery and affect outcomes during this critical period of hemodynamic support. The objective of this study was to analyze the mortality related to the micro-organism isolated in children with ECMO after surgery for CHD.MethodsRetrospective cohort study from January 2014 to December 2021 at a university hospital in Colombia. The primary outcome was the infection-related inpatient mortality of children undergoing surgery for CHD who received ECMO support, according to the type of microorganisms isolated in cultures.ResultsA total of 3307 surgeries for CHD were performed during the study period. Of these, 108 (3.3%) required veno-arterial ECMO after surgery. We found positive cultures in 35% of these patients. The incidence of infection was 14.5 cases per 1000 days of ECMO. The overall mortality of infected patients was 54.1%. Isolation of Gram-negative bacteria in cultures was associated with higher odds of dying compared with other isolations, regardless of age and type of CHD (aOR 6.92 95% CI 1.91-25.02; p < .01). We found no differences in hospital length of stay or PICU stay based on the type of bacteria isolated. The most commonly isolated Gram-negative bacteria was <i>Klebsiella pneumoniae</i>, which was associated with longer mechanical ventilation [26 (IQR 18.2-31.0) versus 11 (IQR 8.0-15.0) days; p < .01].ConclusionsThe presence of a Gram-negative bacterium as the cause of infection in any sample was associated with increased odds of mortality in children receiving ECMO support in the postoperative period following corrective surgery for congenital heart disease. Infections occurred in 1 out of 3 children on ECMO following surgery for CHD.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"956-963"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143692589","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Type 2 Myocardial Infarction and Inpatient Mortality in Septic Shock: Insights from a Nationally Representative Sample.","authors":"Boluwaduro Adeyemi, Oluwafunmbi Fatunmbi, Kayode Ogunniyi, Jesus Antonio Galindo Castaneda, Elizabeth Retzer","doi":"10.1177/08850666251368272","DOIUrl":"https://doi.org/10.1177/08850666251368272","url":null,"abstract":"<p><p>Type 2 myocardial infarction (type 2 MI) caused by demand ischemia and characterized by an imbalance between myocardial oxygen supply and demand without acute athero-thrombosis, is common in critically ill patients, including those with septic shock. This study aimed to evaluate the relationship between type 2 MI and inpatient mortality in patients hospitalized with septic shock using the National Inpatient Sample (NIS) from 2016 to 2020. A propensity-matched cohort was constructed, consisting of 31,905 hospitalizations with septic shock and type 2 MI (study group) and an equal number without type 2 MI (control group).Overall, type 2 MI was not associated with a statistically significant difference in mortality (27% vs 26.1%, OR 1.05, 95% CI 0.97-1.14, p = 0.23). Subgroup analysis revealed an increased mortality risk in younger patients (aged 18-39) with type 2 MI (OR 1.93, 95% CI 1.09-3.43, p = 0.024). Conversely, patients with coronary artery disease (CAD) and type 2 MI demonstrated a lower mortality risk (OR 0.82, 95% CI 0.70-0.96, p = 0.012). Other comorbidities, including chronic heart failure, tachyarrhythmias, chronic kidney disease, and iron deficiency anemia, did not significantly alter mortality outcomes. These findings suggest that type 2 MI may be correlated with inpatient mortality only in specific subgroups of patients with septic shock, particularly younger patients and those with CAD. Our findings underscore the importance of demographic characteristics and comorbidities as key determinants of outcomes. Further research is needed to elucidate underlying mechanisms and improve clinical management in these populations.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"8850666251368272"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144957350","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Applications of Polymyxin B Hemadsorption in Sepsis and Septic Shock.","authors":"Fiorenza Ferrari, Yaroslava Longhitano, Antonio Voza, Jacopo Fumagalli, Gabriele Savioli, Christian Zanza, Giacomo Grasselli","doi":"10.1177/08850666251368803","DOIUrl":"https://doi.org/10.1177/08850666251368803","url":null,"abstract":"<p><p>Sepsis and septic shock (SS) represent complex, life-threatening conditions driven by a dysregulated host immune response, leading to multi-organ failure (MOF). The SEPSIS-3 guidelines have emphasized the role of immunology in defining sepsis, but therapies targeting individual mediators have largely failed. Hemoadsorption (HA), particularly with polymyxin B (PMX), presents a promising approach to modulate this immune response by non-specifically removing endotoxins and other mediators, potentially restoring physiological homeostasis. This review explores the use of PMX hemoperfusion (PMX-HA) over the last 20 years in critically ill patients, examining its role in sepsis, particularly in endotoxemic septic shock. PMX-HA works by targeting endotoxin removal, reducing inflammatory mediators, and modulating immune cell activity, including neutrophil and monocyte function. However, treatment success varies due to patient heterogeneity. Identifying optimal target populations, based on markers like endotoxin activity (EAA), SOFA scores, and lactate levels, is critical for determining the timing, dose, and duration of PMX-HA therapy. Recent studies have highlighted the importance of stratifying patients by severity and endotoxin burden, suggesting that PMX-HA is most beneficial for patients with high endotoxin activity and severe organ dysfunction. Additionally, prolonged PMX-HA sessions may improve outcomes in patients with sustained endotoxin levels. This review emphasizes the need for a personalized approach to PMX-HA, with tailored treatment protocols to optimize clinical outcomes in sepsis and septic shock patients. Future research should focus on refining patient selection criteria and determining the most effective treatment regimens.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"8850666251368803"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144957536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association of Admission Times on Mortality in Adult Patients with Severe Community-Acquired Pneumonia.","authors":"You-Lian Zhou, Shijie Duan, Xingmei Zhong, Liang Yang, Jun Qiu","doi":"10.1177/08850666251332116","DOIUrl":"10.1177/08850666251332116","url":null,"abstract":"<p><p>ObjectivesThe objective of this study was to examine the association between admission time and in-hospital mortality in patients with severe community-acquired pneumonia.Research DesignThe study population consisted of individuals who were enrolled between January 2019 and December 2023. These individuals were divided into two groups based on the time of admission: daytime admission from 8:00 am to 6:00 pm and nighttime admission from 6:00 pm to 8:00 am The primary endpoint of the study was in-hospital mortality. Binary logistic regression was employed to assess the association between admission time and in-hospital mortality.ResultsA total of 307 patients with severe community-acquired pneumonia were ultimately enrolled in the study. Of the total number of patients, 57% (175 patients) were admitted at night. A comparative analysis of the clinical outcomes in the two groups revealed that the mortality rate for patients admitted at night was 28%, which was not significantly different from that of patients admitted during the day, which was 35.6% (<i>P</i> = .155). The findings from binary logistic regression analyses revealed no statistically significant correlation between nighttime admissions and in-hospital mortality.ConclusionsThis study's findings indicate that nighttime admission for patients diagnosed with severe community-acquired pneumonia is not associated with an elevated risk of mortality. Conversely, there may be a reduced mortality rate for patients admitted during nighttime hours. However, further prospective multicenter studies are required in the future to confirm this.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"985-992"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144005142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Practice Variation in Arterial Catheter Placement: A Survey of Pediatric Critical Care Practitioners.","authors":"Mary S Pilarz, Christopher D Mattson, Cara M Pritchett, Amelia K Rountree, Matthew J Rowland","doi":"10.1177/08850666251363551","DOIUrl":"https://doi.org/10.1177/08850666251363551","url":null,"abstract":"<p><p>BackgroundThere is not a consensus in critical care medicine on when arterial catheters are indicated, nor is there evidence that ACs improve patient outcomes. There is wide variability in AC use across PICUs that is independent of illness severity.ObjectiveTo characterize arterial catheter placement practices among pediatric critical care clinicians and identify practice variability in techniques, indications, and attitudes.DesignAnonymous, cross-sectional web-based survey.Measurements and Main ResultsData were collected from 377 pediatric critical care practitioners across 93 institutions. The majority were attending physicians (n = 215, 57.0%) or fellows (n = 141, 37.4%). Ultrasound was always used for arterial catheter placement by 52.0% (196/377) of respondents, with fellows being more likely than attendings to use ultrasound (<i>P</i> = .005). The catheter-over-wire (Seldinger) technique was the most common insertion method (332/377, 88.1%). For site selection, the radial artery was preferred for peripheral placement (97.3%), and the femoral artery for central cannulation (81.1%). There was substantial variability in the reported indications for arterial catheter use, with 68.9% considering single vasoactive support as an indication.ConclusionsThis study demonstrates wide practice variation in arterial catheter placement among pediatric ICU clinicians, despite the existence of some practice guidelines. Future research should focus on addressing gaps in evidence, particularly around ultrasound-guided techniques and securement methods, to optimize practices and improve outcomes.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"8850666251363551"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144957313","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Decision-Making About Potentially Non-Beneficial Intensive Care Unit Treatments: Interviews of Family Members from an Academic Public Hospital.","authors":"Jennifer Parrish, Thanh H Neville, Derjung M Tarn, Dong W Chang","doi":"10.1177/08850666251371579","DOIUrl":"https://doi.org/10.1177/08850666251371579","url":null,"abstract":"<p><p>ObjectiveDeveloping effective strategies to improve shared decision-making (SDM) about potentially non-beneficial intensive care unit (ICU) treatments for patients with advanced medical illness requires understanding patients' and family members' perspectives. This study explores family members' experiences in discussing potentially non-beneficial treatments with ICU clinicians to identify factors that influenced their decision-making.MethodsSemi-structured interviews of pre-dominantly non-White family members making decisions about potentially non-beneficial ICU treatments were conducted in the medical ICU of an academic public hospital in Los Angeles County. Interviews were audio-recorded, transcribed, and analyzed using thematic analysis.ResultsEighteen surrogate decision-makers were interviewed for this study. Perceived barriers to decision-making included intimidation, dehumanizing family meetings, time-pressure to make decisions, and uncertainty of benefit from ICU treatments. Factors that affected the perceived susceptibility from harm or likelihood of benefit from invasive treatments included health status prior to hospitalization, physicians' discussion of prognoses, and direct observation of clinical status during ICU hospitalization. Greater self-efficacy in making decisions was promoted by stronger family support, gaining experience with the clinical situation, and empathic characteristics of the clinical team.ConclusionsInterviews with family members at a single ICU revealed that strategies to improve decision-making may include emphasizing empathic communication styles that focus on patients' values and preferences for care, reducing time-pressure and uncertainty by seeing the effects of ICU treatments, and creating time for families to adjust and seek social support. Adopting this approach may allow ICU clinicians and family members to become more aligned in their efforts to provide compassionate care for patients while minimizing non-beneficial treatments. These findings need to be validated in larger patient populations.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"8850666251371579"},"PeriodicalIF":2.1,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144957503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Experiences of Moral Distress in Canadian Intensive Care Unit Professionals During and After the COVID-19 Pandemic: A Qualitative Exploratory Multiple Case Study in Ontario and Alberta, Canada.","authors":"Monica L Molinaro, Aimun Qadeer Shah, Asiana Elma, Alison Scholes, Nicole Pinto, Myles Leslie, Allison Brown, Deborah Cook, Daniel Niven, Kirsten Fiest, Elizabeth Peter, Lawrence Grierson, Meredith Vanstone","doi":"10.1177/08850666251329828","DOIUrl":"10.1177/08850666251329828","url":null,"abstract":"<p><p><b>Background:</b> Since the beginning of the COVID-19 pandemic, moral distress among healthcare workers in the Intensive Care Unit (ICU) has garnered both media and academic attention. Moral distress has been theorized as occurring when individuals are constrained from doing what they perceive as morally right. This study sought to empirically examine the lived experiences of moral distress among clinical and administrative healthcare professionals in a sample of Canadian ICUs during the COVID-19 pandemic. <b>Methods:</b> Qualitative case study methodology was used as the overarching approach, collecting and comparing data from two distinct cases: one ICU in Ontario and one in Alberta. Data collection involved two primary sources: semi-structured interviews with staff and document review of institutional and government directives to provide contextual data. Data analysis commenced concurrently with data collection, and generated within- and across-case themes, as well as allowed descriptive accounts of moral distress. <b>Results:</b> Thirty-six healthcare workers across two sites were interviewed. Participants described three primary categories of constraints leading to moral distress. These were: 1) The rapidity and opaqueness of policy development, specifically pertaining to 2) the implementation of family visitation and treatment triage decisions, and 3) resource shortages, which reduced patient interactions, shifted professional responsibilities. Each of these constraints yielded circumstances and forced decisions that were perceived as morally wrong because they compromised care quality and outcomes. <b>Conclusions:</b> While sharing similarities with the growing literature on moral distress in the context of the COVID-19 pandemic, this study reveals new insights on how provincial and institutional policy has direct bearing on experiences of moral distress. Policies and circumstances forced ICU staff to choose between actions they considered the most right and the least wrong. Understanding these specific policy-driven constraints highlights the need for healthcare systems and processes that mitigate moral distress and sustain our health workforce.</p>","PeriodicalId":16307,"journal":{"name":"Journal of Intensive Care Medicine","volume":" ","pages":"973-984"},"PeriodicalIF":3.0,"publicationDate":"2025-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12231837/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143970184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}