American Journal of Critical Care最新文献

{"title":"Effect of a Machine Learning Algorithm to Guide Goal-Directed Therapy After Cardiac Surgery.","authors":"Amanda Rea, Alexandra Deasel, Clifford Edwin Fonner, Rawn Salenger","doi":"10.4037/ajcc2026587","DOIUrl":"https://doi.org/10.4037/ajcc2026587","url":null,"abstract":"<p><strong>Background: </strong>Goal-directed therapy allows clinicians to optimize perfusion and volume status in patients postoperatively.</p><p><strong>Objective: </strong>To evaluate the effect of a machine learning algorithm to guide postoperative goal-directed fluid therapy in cardiac surgery patients.</p><p><strong>Methods: </strong>A goal-directed fluid therapy program was implemented in a single center for coronary artery bypass patients with ejection fraction greater than or equal to 45% (implementation period: May 15, 2023, to May 31, 2024). Patient outcomes were compared with outcomes in matched historical control patients (control period: January 3 to October 31, 2022). The primary outcome was acute kidney injury.</p><p><strong>Results: </strong>A total of 479 eligible patients were evaluated (246 in the control group and 233 in the goal-directed therapy group). The incidence of acute kidney injury on postoperative day 2 (P = .01), on postoperative day 7(P = .02), and at discharge (P = .008) was lower in the goaldirected therapy group than in the control group.</p><p><strong>Conclusions: </strong>Patients in the goal-directed therapy program had a lower incidence of acute kidney injury compared with historical control patients. Incorporating a machine learning algorithm to guide goal-directed fluid therapy was a safe and less invasive way to monitor selected patients in the intensive care unit after cardiac surgery.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"378-383"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863338","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":"Validation of AACN's Healthy Work Environment Assessment Tool-Team.","authors":"Jean Anne Connor, Jason Thornton, Patricia Dwyer, Kimberlee Gauvreau, Sherri Kubis, Justine Fortkiewicz, Audrie Kocol, Deniro Brown, Alissa Martin, Amelia Wirth, Alexandra Dixon, Micayla Johnson, Allie Pesche, Rheannon Rae Rzucidlo, Chloe Kight, Elizabeth Casto, Hangying She, Zachary DiPasquale, Patricia A Hickey","doi":"10.4037/ajcc2026344","DOIUrl":"10.4037/ajcc2026344","url":null,"abstract":"<p><strong>Background: </strong>In 2024, the American Association of Critical-Care Nurses (AACN) updated the Healthy Work Environment Assessment Tool (HWEAT), renamed HWEAT-Team.</p><p><strong>Objective: </strong>Validating HWEAT-Team for interprofessional use.</p><p><strong>Methods: </strong>This was a multisite, descriptive, nonexperimental correlation survey study. A demographics survey, the HWEAT, the HWEAT-Team, and the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture 2.0 (H-SOPS 2.0) were administered via REDCap to interprofessional staff across 11 pediatric intensive care units. Responses were aggregated as overall mean score and a score for each standard. Test-retest reliability and internal consistency were assessed. Construct validity was measured by correlating HWEAT, HWEAT-Team, and AHRQ H-SOPS 2.0 overall scores. Differences in HWEAT-Team scores by health care role also were examined.</p><p><strong>Results: </strong>Among 733 participants (39% response rate), the overall HWEAT-Team mean score was 4.01. Test-retest reliability indicated a Spearman correlation coefficient of 0.85 overall score (range for standards, 0.68-0.80) and internal consistency revealed a Cronbach α of 0.78 (range, 0.71-0.91). Convergent validity between the HWEAT and HWEAT-Team revealed a correlation coefficient of 0.86 overall score (range for standards, 0.60-0.73), and for the HWEAT-Team and AHRQ H-SOPS 2.0, a correlation coefficient of 0.46. Direct care registered nurses rated the work environment less positively than physicians did for the Effective Decision-Making (P = .02) and Meaningful Recognition (P = .03) standards.</p><p><strong>Conclusions: </strong>The HWEAT-Team was reliable, valid, and supportive of interprofessional use. Active evaluation of care environments is essential to support clinical excellence and achievement of optimal patient outcomes. Understanding differences across health care roles can guide targeted improvements.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"344-352"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863376","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":"Plateau Pressure Exceeding Peak Inspiratory Pressure During Pressure Mode Ventilation With Active Inspiratory Effort.","authors":"Hassan Sajjad, Tracy Steffes, Samuel Haen, Harold Winnike, Daniel P McCarthy, Hilary Faust, Michael Eberlein","doi":"10.4037/ajcc2026219","DOIUrl":"10.4037/ajcc2026219","url":null,"abstract":"<p><strong>Background: </strong>In patients receiving pressure modes of mechanical ventilation, plateau pressure can be higher than peak inspiratory pressure when the patient has a strong drive to breathe. This report provides comprehensive evidence to support this observation.</p><p><strong>Methods: </strong>Peak inspiratory pressure, plateau pressure, esophageal pressure, and tidal volume were observed at various levels of pressure support in a patient with absent cortical function but preserved brainstem function who was receiving mechanical ventilation.</p><p><strong>Results: </strong>Positive end-expiratory pressure was 5 cm H2O for all pressure support settings. At pressure support of 0 cm H2O, plateau pressure was 13 cm H2O; peak inspiratory pressure was 5 cm H2O. The difference between plateau pressure and peak inspiratory pressure (8 cm H2O) reflected the patient's inspiratory effort. The driving pressure (8 cm H2O) generated a tidal volume of 619 mL. At pressure support of 10 cm H2O, plateau pressure was 12 cm H2O; peak inspiratory pressure was 15 cm H2O. The difference between plateau pressure and peak inspiratory pressure was -3 cm H2O, indicating absent inspiratory effort apart from triggering the breath. The driving pressure (7 cm H2O) generated a tidal volume of 563 mL.</p><p><strong>Conclusion: </strong>When plateau pressure can be accurately measured, the difference between plateau pressure and peak inspiratory pressure can be used at the bedside to evaluate a patient's respiratory drive. Ensuring protective goals by routinely monitoring plateau pressure regardless of the mode of mechanical ventilation is critical.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"389-394"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863424","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":"Teaching Engagement and Caregiving Help in the Intensive Care Unit (TEACH-ICU) Scale: Content Validity.","authors":"Kimberly A Haag, Amy B Petrinec, Denice Sheehan","doi":"10.4037/ajcc2026730","DOIUrl":"https://doi.org/10.4037/ajcc2026730","url":null,"abstract":"<p><strong>Background: </strong>Having family members provide care to their loved ones in the intensive care unit (ICU) is a beneficial yet seldom implemented approach. For family members to perform caregiving, nurses must be willing to teach, and such willingness is a developing area of research.</p><p><strong>Objectives: </strong>To adapt an instrument validated in family members, the Family Willingness for Caregiving Scale, to address nurses' willingness to teach family members caregiving skills.</p><p><strong>Methods: </strong>Purposive and snowball sampling were used to recruit 10 expert ICU nurses through the American Association of Critical-Care Nurses' research website and social media platforms. The researchers conducted cognitive interviews with the nurses to address the instrument's content validity.</p><p><strong>Results: </strong>The scale was refined based on the participants' feedback. Items were deleted, added, and revised. Furthermore, scale instructions were adjusted to emphasize the willingness to teach families of patients receiving mechanical ventilation. Qualitative themes emerged related to barriers to family engagement, including time constraints, patient acuity, and nurse and family characteristics.</p><p><strong>Conclusions: </strong>Content validity of the scale was assessed, with future research aimed at pilot testing and evaluating construct validity before using the scale as a research instrument. Practical implications include using the scale as an evaluation tool to determine nurses' willingness to teach family members about caregiving. After evaluation, various strategies could be incorporated to enhance family engagement in adult ICUs.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"371-377"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863381","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":"Measuring What Matters: HWEAT-Team and Interprofessional Healthy Work Environments.","authors":"Meredith Padilla","doi":"10.4037/ajcc2026595","DOIUrl":"https://doi.org/10.4037/ajcc2026595","url":null,"abstract":"","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"353"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863349","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":"Feasibility of Prone Positioning in Patients With Obesity and Acute Respiratory Distress Syndrome.","authors":"Caleb Lee, Alexandra Paxitzis, Omar M Mehkri, Lynne Kokoczka, Shuaiqi Huang, Xiaofeng Wang, Shewit Giovanni, Eduardo Mireles-Cabodevila, Sudhir Krishnan, Abhijit Duggal","doi":"10.4037/ajcc2026929","DOIUrl":"https://doi.org/10.4037/ajcc2026929","url":null,"abstract":"<p><strong>Background: </strong>Prone positioning in patients with obesity remains uncommon because of concerns about feasibility, safety, and efficacy.</p><p><strong>Objective: </strong>To evaluate the feasibility, safety, and clinical outcomes of manual prone positioning in patients with acute respiratory distress syndrome (ARDS) across different classes of obesity.</p><p><strong>Methods: </strong>This was a retrospective cohort study involving patients with ARDS who underwent manual prone positioning across 15 hospitals between April 2014 and July 2024. Patients were stratified into 5 groups based on body mass index. Standardized prone positioning protocols were followed across institutions.</p><p><strong>Results: </strong>A total of 1448 patients with ARDS underwent prone positioning. Across all obesity categories, prone positioning was associated with shorter intensive care unit and hospital stays, improved oxygenation, and better clinical outcomes. Notably, patients with class III obesity showed the greatest increase in gas exchange efficiency, with a 37% improvement in ratio of Pao2 to fraction of inspired oxygen, compared with 28% in patients with normal weight (P < .05). Complication rates were low across all groups.</p><p><strong>Conclusions: </strong>Prone positioning is feasible and safe in patients with ARDS across all obesity classes. Patients with class III obesity showed the greatest improvements in oxygenation. Future prospective studies should further explore the long-term impact of prone positioning in patients with class III obesity to refine clinical guidelines and optimize care.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 5","pages":"354-361"},"PeriodicalIF":2.6,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148863267","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 Utility of β-Hydroxybutyrate vs Anion Gap to Define Resolution of Diabetic Ketoacidosis.","authors":"Alexandra Cyr, Andrew Faust, Margarita Taburyanskaya, Thomas Brad Raper, Anthony Ortegon","doi":"10.4037/ajcc2026208","DOIUrl":"10.4037/ajcc2026208","url":null,"abstract":"<p><strong>Background: </strong>Updated guidelines for managing diabetic ketoacidosis (DKA) preferentially recommend using β-hydroxybutyrate instead of anion gap for determining DKA resolution. Although physiological reasons suggest benefits of β-hydroxybutyrate over anion gap, clinical data supporting this idea are limited.</p><p><strong>Objective: </strong>To compare time to DKA resolution (time from initial intravenous insulin to first dose of long-acting subcutaneous insulin) between patients managed with β-hydroxybutyrate and patients managed with anion gap.</p><p><strong>Methods: </strong>This retrospective study evaluated patients with DKA who were managed with the same continuous intravenous insulin protocol at 2 participating sites, one that used β-hydroxybutyrate and the other that used anion gap to assess resolution. The primary outcome was time to first dose of long-acting insulin, with secondary outcomes including incidence of DKA recurrence after transition to subcutaneous insulin.</p><p><strong>Results: </strong>A total of 178 patients were included, with 89 in the β-hydroxybutyrate-managed arm. Baseline characteristics, including DKA severity, were similar in the 2 groups. Conversion to a long-acting insulin regimen occurred at a median (IQR) of 23.5 (17.9-31.0) hours in the β-hydroxybutyrate group and 13.3 (10.0-18.2) hours in the anion gap group (P < .01) with no difference in rates of DKA recurrence.</p><p><strong>Conclusions: </strong>Monitoring anion gap rather than β-hydroxybutyrate for DKA resolution led to shorter time on an insulin infusion with no increase in DKA recurrence. Prospective studies evaluating β-hydroxybutyrate thresholds or how to best use β-hydroxybutyrate in practice are warranted.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 4","pages":"298-303"},"PeriodicalIF":2.6,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148359031","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":"Discussion Guide for the Nagura Article.","authors":"Grant A Pignatiello","doi":"10.4037/ajcc2026843","DOIUrl":"https://doi.org/10.4037/ajcc2026843","url":null,"abstract":"","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 4","pages":"286-287"},"PeriodicalIF":2.6,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148358742","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":"Mobilizing Survival: Addressing ICU-Acquired Weakness Through Early Intervention.","authors":"Cindy Cain","doi":"10.4037/ajcc2026281","DOIUrl":"https://doi.org/10.4037/ajcc2026281","url":null,"abstract":"","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 4","pages":"288"},"PeriodicalIF":2.6,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148358772","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":"Medication Lost During Administration of Crushed Pills.","authors":"Christina Nolaly, Olivia Swyers, Jamie Buttram, D Philip Colombo, Teresa Myers, Tyler Smith, Theresa Sudholt, Marci Ebberts","doi":"10.4037/ajcc2026165","DOIUrl":"10.4037/ajcc2026165","url":null,"abstract":"<p><strong>Background: </strong>For patients requiring oral medications but unable to swallow, common nursing practice is to crush the pill, suspend it in water, and administer it via syringe through a gastric tube. Nurses have observed residue left during this process, potentially affecting prescribed dosage.</p><p><strong>Objective: </strong>To quantify aspirin lost during administration of a crushed pill.</p><p><strong>Methods: </strong>Nurse researchers partnered with a university chemistry laboratory for this study. A 325-mg aspirin tablet was crushed in a plastic sleeve with a pill crusher, tapped into a medication cup, suspended in water, and injected through a gastric tube into a flask; the tube was then rinsed with additional water. This slurry was dissolved in 100 mL isopropyl alcohol, diluted to 1 L with deionized water, and analyzed with ultraviolet-visible spectroscopy. Light absorbance at 231 nm was compared with a known solution to measure how much aspirin reached the flask. This process was repeated 5 times. Calculations based on data from these experiments quantified aspirin lost during crushing, suspending, and delivering the aspirin to a flask.</p><p><strong>Results: </strong>For the 5 trials, a mean (SD) of 22.0% (3.1%) of aspirin was lost during the process of crushed pill administration. A mean (SD) of 5.7% (2.7%) was lost in the sleeve and cup, and the remainder was lost between the syringe and the final collection flask.</p><p><strong>Conclusions: </strong>Quantifying medication loss during the practice of crushing pills for delivery via gastric tube has implications for medication administration.</p>","PeriodicalId":7607,"journal":{"name":"American Journal of Critical Care","volume":"35 4","pages":"304-308"},"PeriodicalIF":2.6,"publicationDate":"2026-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148358758","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}