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Care Guided by PCT Measurement Reduces Antibiotic Duration for Patients With Sepsis

An RCT in JAMA investigated whether decisions based on assessment of CRP or PCT safely results in reduced duration of antibiotic therapy for hospitalized patients with sepsis. Antibiotic duration was significantly reduced from randomization to 28 days for 918 patients in the daily PCT-guided protocol compared with 918 patients receiving standard care (mean duration 10.7 [SD, 7.6] days for standard care and 9.8 [SD, 7.2] days for PCT; mean difference 0.88 days; 95% CI, 0.19 to 1.58, P = .01). For all-cause mortality up to 28 days, the daily PCT-guided protocol was noninferior to standard care, where the noninferiority margin was set at 5.4% (19.4% [170 of 878] of patients receiving standard care; 20.9% [184 of 879], PCT; absolute difference, 1.57; 95% CI, –2.18 to 5.32; P = .02). There was no difference in antibiotic duration for 924 patients assigned to the daily CRP-guided protocol vs. 918 patients receiving standard care. For all-cause mortality, the daily CRP-guided protocol was inconclusive compared with standard care.

Diagnostic Uncertainty Is Common Among Critically Ill Children Admitted to the PICU

A multicenter retrospective cohort study in Critical Care Medicine used a standardized instrument to identify diagnostic uncertainty in narrative clinical notes of 882 randomly selected patients < 18 years old who were nonelectively admitted to participating PICUs. PICU admission notes for 25.9% of patients indicated diagnostic uncertainty. Diagnostic uncertainty was significantly associated with off-hours admission (OR 1.52; P = 0.037), greater severity of illness (OR 1.04; P = 0.025), atypical presentation (OR 2.14; P = 0.046), diagnostic discordance at admission between attending intensivists and resident physicians/advanced practice providers (OR 3.62; P < 0.001), and having a neurologic primary diagnosis (OR 1.87; P = 0.03).

Dexmedetomidine Improves Sleep Quantity and Quality in ICU Patients

A systematic review in the Journal of Intensive Care Medicine assessed the objective and subjective effects of sleep aids in the ICU. The review included 34 studies with 3498 participants and evaluated melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. These medications were reported to be safe. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased stage N1 sleep, and increased stage N2 sleep. Mild bradycardia and hypotension were reported as side effects.

Muscle Mass Decreases by Nearly 10% During a Child's First Week in the PICU

A systematic review and meta-analysis in the Journal of Parenteral and Enteral Nutrition examined muscle mass changes, assessed by ultrasound of the quadriceps femoris muscle in critically ill children. Eight prospective cohort studies were included, involving 411 children. Overall, muscle mass changes reported in 7 of the 8 papers showed a pooled mean muscle mass loss of 8.9% (95% CI, 6.6-11.4) from baseline to days 5-7. Five of the 8 publications defined muscular atrophy as a decrease in muscle mass of >10%. Using this cutoff, 92 (49.2%) children developed muscular atrophy during their PICU stay. Overall, muscle mass decreased by nearly 10% during a child's first week in the PICU, with almost half of children developing muscular atrophy during their stay.

Higher Energy Delivery Does Not Improve Survival in Adult Critically Ill Patients Diagnosed With or at Risk of Malnutrition

A systematic review and meta-analysis in Nutrition Reviews evaluated 2 RCTs (4681 at-risk patients) and 5 observational studies (1587 at-risk patients [including 389 high-risk patients]). Patients had at least 20% energy difference between intervention and comparison groups. No mortality difference was found between higher vs. lower energy groups in at-risk patients (risk ratio 0.99; 95% CI, 0.85-1.17; P = .94) in RCTs and high-risk patients (adjusted odds ratio 1.37; 95% CI, 0.43-4.32; P = .59) in observational studies. Trial sequential analysis showed that 31,232 patients were required to show a potential treatment effect.

Family Participation Interventions Help Prevent Delirium in ICU Patients

A systematic review in Intensive and Critical Care Nursing assessed the effect of family participation interventions in preventing delirium in ICU patients. Fourteen studies were included, involving 33,232 patients. Familiar voice messages, flexible visitation, and family presence had favorable impacts on reducing delirium. Multicomponent interventions including 1) family visitation with professional-guided orientation, 2) familiar voice messages for reorientation, newspaper reading, and nighttime eye patch use, 3) sensory stimulation program, 4) the ABCDEF bundle, 5) the DyDel program, and 6) family education, emotional support, orientation training, cognitive stimulation, and ICU life care participation also had positive effects.

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