美国重症监护杂志 (AJCC) 的编辑邀请作者提交原始手稿，描述与重症和急性病患者护理相关的所有专业的调查、进展或观察。鼓励合作实践和研究的论文。稿件将被考虑，但前提是它们尚未在其他地方发表并且仅提交给 AJCC。

The editorial team of the American Journal of Critical Care invites authors to submit original manuscripts that describe investigations, advancements, or observations related to the care of critically ill and acutely ill patients. We encourage papers that promote collaborative practice and research. Manuscripts will be considered only if they have not been published elsewhere and are submitted exclusively to this journal.

美国重症监护杂志 (American Journal of Critical Care) 编辑诚邀作者提交原创手稿，内容涉及重症和急性病患者护理相关的各类研究、进展或观察。我们鼓励提交合作实践和研究的论文。所有稿件必须为未在其他地方发表且仅提交给本杂志。

American Journal of Critical Care

The role of fever in trauma patients remains unclear. Fever occurs as a response to release of cytokines and prostaglandins by white blood cells. Many factors, including trauma, can trigger release of these factors.To determine whether (1) fever in the first 48 hours is related to a favorable outcome in trauma patients and (2) fever is more common in patients with head trauma.Retrospective study of trauma patients admitted to the intensive care unit for at least 2 days. Data were analyzed by using multivariate analysis.Of 162 patients studied, 40% had fever during the first 48 hours. Febrile patients had higher mortality rates than did afebrile patients. When adjusted for severity of injuries, fever did not correlate with mortality. Neither the incidence of fever in the first 48 hours after admission to the intensive care unit nor the number of days febrile in the unit differed between patients with and patients without head trauma (traumatic brain injury). About 70% of febrile patients did not have a source found for their fever. Febrile patients without an identified source of infection had lower peak white blood cell counts, lower maximum body temperature, and higher minimum platelet counts than did febrile patients who had an infectious source identified. The most common infection was pneumonia.No relationship was found between the presence of fever during the first 48 hours and mortality. Patients with traumatic brain injury did not have a higher incidence of fever than did patients without traumatic brain injury. About 30% of febrile patients had an identifiable source of infection. Further studies are needed to understand the origin and role of fever in trauma patients.

Victoria Bengualid

Goutham Talari

David Rubin

Aiham Albaeni

Ronald L. Ciubotaru

Judith Berger

Fever in Trauma Patients: Evaluation of Risk Factors, Including Traumatic Brain Injury

创伤患者发热：评估风险因素，包括创伤性脑损伤

Little information is available on the use of tools in intensive care units to help nurses determine when to restrain a patient. Patients in medical-surgical intensive care units are often restrained for their safety to prevent them from removing therapeutic devices. Research indicates that restraints do not necessarily prevent injuries or removal of devices by patients.To decrease use of restraints in a medical-surgical intensive care unit and to determine if a decision support tool is useful in helping bedside nurses determine whether or not to restrain a patient.A quasi-experimental study design was used for this pilot study. Data were collected for each patient each shift indicating if therapeutic devices were removed and if restraints were used. An online educational activity supplemented by 1-on-1 discussion about proper use of restraints, alternatives, and use of a restraint decision tool was provided. Frequency of restraint use was determined. Descriptive statistics and thematic analysis were used to examine nurses' perceptions of the decision support tool.Use of restraints was reduced 32%. No unplanned extubations or disruption of life-threatening therapeutic devices by unrestrained patients occurred.With implementation of the decision support tool, nurses decreased their use of restraints yet maintained patients' safety. A decision support tool may help nurses who are undecided or who need reassurance on their decision to restrain or not restrain a patient.

Stacy Hevener

Barbara Rickabaugh

Toby Marsh

Using a Decision Wheel to Reduce Use of Restraints in a Medical-Surgical Intensive Care Unit

使用决策轮减少内外科重症监护病房约束措施的使用

The phenomenon of skin failure as distinct from pressure ulcers has been documented in the adult literature. However, in the pediatric population, skin injury continues to be grouped indiscriminately as various types of pressure ulcers.To identify and describe the phenomenon of skin failure in critically ill children.Retrospective chart review of 19 patients who had serious skin injuries develop. Organ dysfunction scores, medications, pressure ulcer prevention techniques used, and laboratory values in the 7 days leading up to the development of a skin lesion were evaluated.At the start of the evaluation period, all patients (N = 19) had pressure ulcer prevention measures in place before the development of a serious skin injury. All of the skin lesions were full-thickness injuries on the day they were identified (as opposed to the more gradual progression from simple to complex skin injuries typically seen in pressure ulcers). As predicted, 18 of 19 patients had multiple organ dysfunction syndrome (MODS) in the week leading up to the skin injury. All patients with MODS had at least 2 dysfunctional systems, and 12 patients had 4 or more dysfunctional systems. Of the 19 patients, 8 (42%) progressed to death, compared with 1.8% in our general pediatric intensive care unit population.Although the traditional paradigm is that pressure ulcers are preventable, a subset of pressure ulcers in critically ill children may actually represent acute skin failure as a consequence of MODS.

Katie E. Cohen

Matthew C. Scanlon

Amin Bemanian

Christine A. Schindler

Pediatric Skin Failure

儿科皮肤衰竭

Background Parents’ perceptions of critical care during the final days of their child’s life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). Objectives To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. Methods A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. Results This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients’ comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, −2; peak, −1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. Conclusion Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents’ ability to connect with their child. Future research should incorporate parents’ perspectives.

Elizabeth G. Broden

Pamela S. Hinds

Allison Werner-Lin

Ryan Quinn

Lisa A. Asaro

Martha A. Q. Curley

Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation

儿科重症监护病房需机械通气患者临终护理

The Withdrawal Assessment Tool-1 (WAT-1) has been validated for assessing iatrogenic withdrawal syndrome in critically ill children receiving mechanical ventilation, but little is known about this syndrome in critically ill adults.To evaluate the validity and reliability of the WAT-1 in critically ill adults.A prospective, observational, open-cohort pilot study of critically ill adults receiving mechanical ventilation and regular administration of opioids for at least 72 hours. Patients were assessed for withdrawal twice daily on weekdays and once daily on weekends using the WAT-1 after an opioid weaning episode. The presence of iatrogenic withdrawal syndrome was evaluated once daily using modified Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) criteria. All evaluations were blinded and performed independently. The criterion validity of the WAT-1 and the interrater reliability for WAT-1 and DSM-5 evaluations were determined.During 8 months, 52 adults (median age, 51.5 years) were enrolled. Eight patients (15%) had at least 1 positive assessment during their intensive care unit stay using the DSM-5, compared with 19 patients (37%) using the WAT-1. The overall sensitivity of the WAT-1 was 50%, and its specificity was 65.9%. Agreement between WAT-1 and DSM-5 assessments was poor (κ = 0.102). The interrater reliability for the WAT-1 was 89.1% and for the DSM-5 was 90.1%.Despite showing reliability, the WAT-1 is not a valid tool for assessing the presence of iatrogenic withdrawal syndrome in adults.

Anissa Capilnean

Amanda Martone

Vlad A Rosu

Patricia R Sandu

Paul Murgoi

Anne Julie Frenette

David Williamson

Annie Lecavalier

Dev Jayaraman

Philippe Rico

Patrick Bellemare

Céline Gélinas

Marc M Perreault

Validation of the Withdrawal Assessment Tool–1 in Adult Intensive Care Patients

成人重症监护患者戒断评估工具-1的验证

Background Although nurses are the primary clinicians in telemedicine intensive care units (tele-ICUs), their experiences remain underresearched. Objective To describe and interpret the lived experiences of tele-ICU nurses. Methods A qualitative, hermeneutical, phenomenological approach based on van Manen’s methodology was used to collect and interpret interview data. In-depth interviews were conducted with 11 tele-ICU nurses affiliated with a health system in the northeastern United States. The interviews were intended to elicit direct reports of specific incidents to capture the phenomenological experience. Field observations of the practice setting were conducted to enhance data richness. Results The participants were primarily female, aged 34 to 67 years, with 11 to 45 years of nursing experience. The following 4 major themes and 12 subthemes were identified: (1) watching intensively and panoptically, with subthemes (a) affirming unremitting diligence, (b) uncovering virtual knowing, and (c) easing perceptions of intrusion; (2) transcending complex boundaries, with subthemes (a) building trustful collaboration, (b) discerning vigilant interventions, and (c) exercising skillful investigation; (3) transforming nursing practice, with subthemes (a) mastering tact, (b) delineating the critical wholeness, and (c) augmenting safety and quality of care; and (4) developing an e-identity, with subthemes (a) tempering feelings of working in shadows, (b) evolving to the enhanced specialist role, and (c) achieving professional gratification. Conclusions Tele-ICU nurses play a transformative role in nursing practice. These findings have implications for nursing practice, education, health policy, enhancement of the current American Association of Critical-Care Nurses (AACN) Tele-ICU Nursing Practice Model, and future research on ICU telemedicine.

Annie George

The Lived Experiences of Telemedicine Intensive Care Unit Nurses

远程医疗重症监护病房护士的亲身体验

Background Hypoalbuminemia has been associated with an increased risk of in-hospital delirium. However, the relationship between serum albumin levels and the duration and severity of delirium is not well defined. Objective To investigate the relationship between albumin levels and delirium duration and severity. Methods Study data were from a randomized controlled trial involving adult intensive care unit patients (≥ 18 years old) admitted to 3 academic hospitals from 2009 to 2015 who had positive delirium screening results on the Confusion Assessment Method for the Intensive Care Unit–7. Delirium severity was defined by mean Confusion Assessment Method for the Intensive Care Unit–7 scores by day 8. Delirum duration was defined by the number of delirium-free and coma-free days by day 8. Serum albumin levels within 72 hours of intensive care unit admission were collected from electronic medical records. Results The study included 237 patients (mean age, 60.3 years; female sex, 52.7%; receiving mechanical ventilation, 59.5%; acute respiratory failure or sepsis, 57.8%). Serum albumin levels were categorized as 3 g/dL or greater (n = 13), 2.5 to 2.99 g/dL (n = 142), and less than 2.5 g/dL (n = 82). After adjustment for demographic and clinical characteristics, no significant associations between albumin levels and delirium duration or severity were found. However, patients with normal albumin levels (≥3 g/dL) had shorter stays than did patients with hypoalbuminemia. Conclusion In patients with delirium, higher albumin levels were associated with shorter hospital stays but not with delirium duration or severity.

Rosalyn Chi

Anthony J. Perkins

Yara Khalifeh

Parth Savsani

Samreen Jawaid

Salwa Moiz

Sophia Wang

Sikandar H. Khan

Sujuan Gao

Babar A. Khan

Serum Albumin Level at Intensive Care Unit Admission and Delirium Duration and Severity in Critically Ill Adults

重症监护病房入院时血清白蛋白水平与重症成人谵妄持续时间和严重程度的关系

Scenario: An 80-year-old man arrived at the emergency department (ED) with general weakness and diffuse chest discomfort. He had undergone a percutaneous coronary intervention (PCI) of a left circumflex artery branch 3 days prior. Echocardiography after PCI showed hypokinesis of the inferoposterior wall. His medical history included hypertension, hyperlipidemia, diabetes mellitus, cerebral ischemic stroke, and coronary artery disease. He had chronic occlusion of the left circumflex artery (stented ~20 years ago). Vital signs on ED arrival: blood pressure, 110/63 mm Hg; heart rate, 45/min; respiratory rate 18/min; and body temperature, 36.9°C. His 0- and 1-hour troponin levels were within the normal limits. His 12-lead electrocardiogram (ECG) recorded upon ED arrival is shown here.Atrial flutter at a rate of 300/min with a slow ventricular rate of 42/min to 50/min; right bundle branch block.Atrial flutter (AFL) is an arrhythmia characterized by rapid atrial depolarizations at a rate of ~250/min to 350/min. It generally results from a reentry mechanism in which an electrical impulse excites and travels slowly around a fixed pathway long enough that the initially excited area recovers quickly and reactivates. This mechanism can occur in either atrium. The AFL presented above is "typical" based on the flutter wave morphology (inverted in inferior leads and positive in V1). Generally, the atrioventricular (AV) node will determine the ventricular response, with a 2:1 conduction AFL frequently countered in clinical settings, in which the AV node would allow every other atrial depolarization to reach the ventricles.When the AV node does not function properly, for example, because of medications (eg, β-blockers), electrolyte imbalances, or a conduction disease, AFL with slow ventricular response (bradycardia) may occur. In the current scenario, the patient had an average ventricular rate of 42/min, which is very low compared with the rapid atrial rate. Notably, 4 flutter waves precede the fifth ventricular beat (4:1 conduction), while the rest of the recording shows a 6:1 conduction, indicating variable conduction, which may be due to varying levels of block in the AV node. It is unclear whether the right bundle branch block seen in lead V1 contributed to the slow ventricular response in this patient. However, in some AFL cases, a partial or complete block of the specialized infranodal conduction system, such as the His bundle and bundle branch, may lead to bradycardia. Whether varying levels of blockade of the AV node and infranodal system are present can be confirmed by an electrophysiological study.Given the recent PCI procedure, the patient was further evaluated for potential restenosis of his stent, which was ruled out following an extensive workup. The patient's chest discomfort was most likely due to the flutter. Given the presence of bradycardia 3 days after PCI, the focus of care is to ensure adequate perfusion and optimize the medical therapy for PCI recovery. Nurses should review at-home medications that could affect AV conduction (eg, β-blockers) and electrolyte levels, such as magnesium. Importantly, the nurse should review the telemetry recording to investigate further other potential abnormal rhythmic patterns that the 12-lead ECG does not capture.Generally, cardioversion is most likely the first line of therapy to control the rhythm. In this scenario, it was not successful in restoring a sinus rhythm. Electrolyte levels were all within normal limits. A later review of the patient's telemetry strip showed that he had alternating bundle branch block, meaning that he had right and left bundle branch block occurring at different times. Alternating block puts the patient at high risk for having both bundle branches blocked simultaneously, which is clinically similar to a complete AV block. After consultation with the electrophysiology team, the patient had a dual-chamber pacemaker implanted to provide chronotropic support, which would maximize the titration of his post-PCI medications. The electrophysiology team followed up to monitor his pacemaker and for further management of his AFL, and he was discharged after 4 days of hospitalization.

Sukardi Suba

Dillon J. Dzikowicz

Mary G. Carey

Chest Discomfort After Percutaneous Coronary Intervention

经皮冠状动脉介入治疗后胸痛

One of the main goals of our nation's Healthy People 2030 initiative is to eliminate health care disparities. In a 2003 report,1 the Institute of Medicine underscores that these disparities are linked to poorer outcomes; it identifies health care systems, health care professionals, and patients themselves as sources of these disparities. One effective way to address this issue involves ensuring the accuracy and integrity of the data collection and the diligence of clinicians in documenting patients' demographic data in the electronic medical record (EMR). In the accompanying study, Colbert et al report that note writers mentioned the patient's self-reported race or ethnicity for 20.8% of Black patients, 10.9% of Latinx patients, 9.1% of White patients, and 4.4% of patients of Asian descent. Demographic data collected in the EMR may include sex assigned at birth, gender identity and sexual orientation, ethnicity, race, primary language, preferred spoken and written language or primary language, and other social constructs deemed necessary. Such information is crucial in empowering health care professionals to effectively address ongoing health disparities and ensure the provision of equitable care.

Abbreviation	Am. J. Crit. Care.
Journal Impact	2.78
Quartiles(Global)	NURSING(Q1)

ISSN	1062-3264, 1937-710X
h-index	92

Publication Information	Publisher: American Association of Critical-Care Nurses，Publishing cycle: Bimonthly，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 1992，Proportion of original research papers: 88.64%，Self Citation Rate:7.40%， Gold OA Rate: 1.27%
Average review cycle	网友分享经验：较慢,6-12周
Average recruitment ratio	网友分享经验：容易

American Journal of Critical Care

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