Hospital Santa Maria Ltda.

Bacterial pulmonary superinfections develop in a substantial proportion of mechanically ventilated COVID-19 patients and are associated with prolonged mechanical ventilation requirements and increased mortality. Albeit recommended, evidence supporting the use of empirical antibiotics at intubation is weak and of low quality. The aim of this study was to elucidate the effect of empirical antibiotics, administered within 24 h of endotracheal intubation, on superinfections, duration of mechanical ventilation, and mortality in mechanically ventilated patients with COVID-19.

Emulated targeted trial by means of a propensity score-matched analysis of a prospective multicentre cohort study of consecutive mechanically ventilated patients admitted to 62 Spanish intensive care units suffering from COVID-19 between March 2020 and February 2021.

Overall, 8532 critically ill COVID-19 patients were included, of which 2580 mechanically ventilated patients remained after matching. Empirical antibiotics were prescribed to 1665 (64%) at intubation. Pulmonary superinfections developed in 39% and 47% of patients treated with and without empirical antibiotics, respectively (p<0.01). Patients treated with empirical antibiotics had a shorter duration of mechanical ventilation (incidence risk ratio: 0.85 [95% confidence interval (CI), 0.78 - 0.94], p<0.01) and a reduced stay in the intensive care unit (incidence risk ratio: 0.89 [95% CI, 0.82 - 0.97] days, p<0.01). Mortality 28 days after endotracheal intubation was 28% in patients treated with empirical antibiotics as opposed to 32% in patients treated without (odds ratio: 0.76 [95% CI, 0.61 - 0.94], p<0.01).

The administration of empirical antibiotics at intubation in mechanically ventilated COVID-19 patients was associated with a reduced incidence of pulmonary superinfections, a shorter duration of mechanical ventilation and intensive care unit stay, and a lower mortality rate. Notwithstanding these benefits, the applicability of these findings to other viral pneumonias and beyond the pandemic context remains uncertain.

www.

gov (NCT04457505).

To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO).

Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented.

Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6 g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7 g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7 g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7 g/dl and 8 g/dl. The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion. Comparing the 2010–2015 to 2016–2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival ( p = .528). Survival to discharge was 68%.

Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7 g/dl and platelets were above 30 x 109/L.

The practice environment influences the quality of care and the nursing outcomes achieved in their workplaces.

To examine the perception of the clinical practice environment among nurses working in mental health units in the context of their participation in an action research study aimed at improving the nurse–patient relationship.

An explanatory sequential mixed methods study was designed. The data were collected in three phases in 18 mental health units ( n = 95 nurses). Quantitative data were collected through the Practice Environment Scale of the Nursing Work Index, and qualitative data were collected through reflective diaries and focus groups in the context of participatory action research.

The nurses’ assessment of their practice environment shifted from positive to negative. Nurse manager leadership was the aspect that worsened the most. In addition, the perception of their participation in the affairs of the center and nursing foundations for quality of care decreased. The nurses considered it essential to be able to influence decision-making bodies and that the institution should promote a model of care that upholds the therapeutic relationship in actual clinical practice.

Nurses perceived that they should be involved in organizational decisions and required more presence and understanding from managers. Furthermore, nurses stated that institutions should promote nursing foundations for quality of care. This study contributes to understanding how nurses in mental health units perceive their work environment and how it affects the improvement of the nurse–patient relationship in clinical practice.