Daily Ards Research Analysis
Analyzed 4 papers and selected 3 impactful papers.
Summary
A large propensity score–matched trauma cohort suggests that early plasma-rich transfusion (FFP:PRBC >1.1) is associated with lower odds of ARDS and AKI without affecting mortality. A structured competency program markedly improved PGY2 nurses’ accuracy in prone positioning care, and a rare case highlights ARDS and critical illness polyneuropathy after tricyclic antidepressant overdose.
Research Themes
- Transfusion strategy and organ protection in trauma
- Implementation science for prone positioning in ARDS
- Toxicology-related ARDS and ICU-acquired weakness
Selected Articles
1. High fresh frozen plasma to packed red blood cell ratios are associated with lower rates of acute kidney injury and acute respiratory distress syndrome in Trauma Quality Improvement Program: A propensity score-matched analysis.
In a TQIP cohort of 50,594 trauma patients, excess FFP:PRBC (>1.1) versus balanced (0.9–1.1) was associated with 40% lower odds of ARDS and 32% lower odds of AKI after matching and adjustment, without a mortality difference. Findings suggest plasma-rich early resuscitation may mitigate organ injury.
Impact: Large, contemporary registry analysis with rigorous matching provides organ-protection signals that could refine trauma transfusion practices beyond the traditional 1:1 paradigm.
Clinical Implications: Consider leaning toward plasma-rich ratios during early trauma resuscitation to reduce ARDS and AKI risk, while recognizing the absence of mortality benefit and the need for randomized trials.
Key Findings
- Excess FFP:PRBC (>1.1) associated with 40% lower odds of ARDS (p<0.001) compared with balanced 0.9–1.1.
- Excess FFP:PRBC associated with 32% lower odds of AKI (p=0.027).
- No difference in in-hospital mortality (OR 1.01; 95% CI 0.92–1.11; p=0.87).
Methodological Strengths
- Large national registry (N=50,594) with robust propensity score matching (16,939 pairs; standardized differences <0.1).
- Multivariable regression and strict exposure definition within a 4-hour early transfusion window.
Limitations
- Retrospective observational design with potential residual confounding and selection bias.
- Database-defined ARDS and AKI; lack of long-term outcomes and granular physiologic data.
Future Directions: Conduct randomized trials comparing FFP:PRBC >1.1 versus 1:1 and investigate mechanistic endothelial protection and dose–response relationships.
BACKGROUND: Balanced transfusion with (1:1:1) ratios of fresh frozen plasma (FFP), packed red blood cells (PRBCs), and platelets is a core tenet of management in traumatic hemorrhagic shock. However, preclinical data suggest that PRBCs transfusion may contribute to endothelial dysfunction, a complication that may be mitigated by FFP. We examined the impact of high FFP:PRBC ratios on mortality and major complications using the American College of Surgeons Trauma Quality Improvement Program database. METHODS: Trauma patients (18 years or older) in Trauma Quality Improvement Program (2017-2022) who received ≥1 U FFP and 1 U PRBC within 4 hours were included. Those transfused with whole blood or FFP:PRBC <0.9 were excluded. Patients were classified as balanced (FFP:PRBC 0.9-1.1) or excess FFP (FFP:PRBC >1.1), propensity matched based on odds of mortality, and compared by multivariate regression. RESULTS: Of 50,594 patients analyzed (75% male; median age, 38 years; Injury Severity Score, 25), 31,960 (63%) were classified as balanced, and 18,634 (37%) as excess FFP. Propensity matching generated 16,939 pairs (mean standard difference, <0.1). After multivariable adjustment, excess FFP was associated with 40% decreased odds of acute respiratory distress syndrome (p < 0.001) and 32% decreased odds of acute kidney injury (p = 0.027) compared with balanced transfusion, with no difference in hospital mortality (odds ratio, 1.01; 95% confidence interval, 0.92-1.11; p = 0.87). CONCLUSION: We found that early excess FFP (FFP:PRBC ratio >1.1) was associated with a significantly decreased odds of key complications compared with a strictly defined balanced transfusion (FFP:PRBC ratio 0.9-1.1), supporting further investigation of the potential benefits of plasma. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.
2. [Project to Improve the Accuracy of Prone Positioning Care Provided by Postgraduate-Year-Two Nursing Staff in the Medical Intensive Care Unit].
A multi-component education and competency program for PGY2 nurses in the MICU increased prone positioning knowledge accuracy from 44.7% to 93.1% and skill accuracy from 77.6% to 93.7%. The initiative addresses rising prone care–related adverse events and provides a scalable training model.
Impact: Prone positioning is mortality-reducing therapy in ARDS; this pragmatic program demonstrates how to reliably build frontline competency, a critical determinant of safe implementation.
Clinical Implications: Institutions can adopt structured, audited prone care training to improve reliability and potentially reduce adverse events during ARDS care, integrating it into onboarding for new ICU nurses.
Key Findings
- Adverse events related to prone care increased by 20.4% year-over-year and were all linked to PGY2 nurse care.
- Program components included education, small-group teaching, videos, competency checklists, simulation dolls, audits, and workshops.
- Knowledge accuracy improved from 44.7% to 93.1% and skill accuracy from 77.6% to 93.7% after implementation.
Methodological Strengths
- Multi-component, structured intervention with objective pre/post competency assessments.
- Embedded auditing and simulation-based training to reinforce skill acquisition.
Limitations
- Single-center before–after design without a control group; causality cannot be established.
- No direct patient-level outcomes (e.g., hypoxemia events, pressure injuries) were reported.
Future Directions: Assess impact on patient outcomes (hypoxemia rates, pressure injuries, mortality) and evaluate scalability across diverse ICUs with cost-effectiveness analyses.
BACKGROUND & PROBLEMS: Acute respiratory distress syndrome, associated with mortality rates as high as 30%, consumes substantial healthcare resources. Prone positioning has been proven to effectively improve patient oxygenation and reduce mortality. A recent analysis in our unit found the incidence of adverse events related to prone positioning care had increased by 20.4% over the previous year and that all of these events were associated with care provided by postgraduate-year-two (PGY2) nurses. PURPOSE: A program was initiated to enhance knowledge and practical skills related to prone positioning care among PGY2 nurses in our unit with the goal of improving the average accuracy rates of both knowledge and skills to at least 85%. RESOLUTION: Program components included: prone care education combined with small-group teaching, producing instructional videos on prone positioning care, designing a prone care competency checklist, developing innovative simulation dolls for skill practice, establishing a regular auditing system for prone care, and organizing periodic in-person skill workshops. RESULTS: After program implementation, the average accuracy of prone care knowledge increased from 44.7% to 93.1% in PGY2 nurses and the average accuracy rate of related practical skills improved from 77.6% to 93.7% in the unit. CONCLUSIONS: Future prone positioning care education and skill assessments should be conducted regularly and incorporated into training programs provided to newly employed nurses. These measures should effectively strengthen the professional competency of intensive care nurses and improve overall patient care quality. TITLE: 提升內科加護病房二年期護理師俯臥照護正確率之專案. 背景: 急性呼吸窘迫症候群（acute respiratory distress syndrome）死亡率高達30%，且耗費醫療資源甚鉅，俯臥治療（prone position）被證實可有效改善病人氧合並降低死亡率。現況分析顯示，本單位2023年俯臥照護異常事件發生率上升20.4%，且皆發生於二年期新進護理師照護期間，因此引發動機來提升俯臥照護能力。. 目的: 提升俯臥照護之認知與執行技能，兩者平均正確率均達85%以上。. 解決方案: 藉由俯臥照護教育訓練課程與小班制教學、製作俯臥照護技術影片、設計俯臥照護流程評核表、開發創新擬真娃娃進行技巧練習、建立俯臥照護定期稽核制度、定期辦理模擬式學習實體操作課程，進而提升認知與技能。. 結果: 經專案改善後，二年期護理師的俯臥照護認知正確率由44.7%提升至93.1%，俯臥照護執行技能正確率由77.6%提升至93.7%，達成專案目標。. 結論: 建議未來持續辦理俯臥照護相關教育訓練與技能評核，並納入新進護理師培訓計畫中，以提升加護病房之專業照護品質。.
3. Survival Following a Tricyclic Antidepressant Overdose Presenting With Serotonin Syndrome-Like Symptoms and Critical Illness Polyneuropathy: A Case Report.
A 54-year-old man with massive amitriptyline overdose presented with serotonin syndrome-like features, progressed to aspiration pneumonia and ARDS requiring prone ventilation, and later developed suspected critical illness polyneuropathy. Management included cyproheptadine, benzodiazepines, antiepileptics, alkalinization, and tracheostomy.
Impact: Educationally valuable case linking TCA intoxication to ARDS and ICU-acquired neuromuscular weakness, emphasizing diagnostic vigilance and comprehensive supportive care.
Clinical Implications: Recognize that TCA overdose can mimic serotonin syndrome and predispose to ARDS and CIP; prioritize early airway protection, consider cyproheptadine when serotonin toxicity is suspected, and monitor for ICU-acquired weakness with rehabilitation planning.
Key Findings
- Massive amitriptyline ingestion (~2,250 mg) led to serotonin syndrome-like presentation with hyperthermia, myoclonus, and altered mental status.
- Hospital course complicated by aspiration pneumonia progressing to ARDS, requiring prone positioning and prolonged ventilation with tracheostomy.
- Later development of suspected critical illness polyneuropathy supported by limb weakness and nerve conduction study findings.
Methodological Strengths
- Detailed temporal clinical course with objective electrophysiologic assessment.
- Comprehensive toxicologic and critical care interventions documented, including prone ventilation.
Limitations
- Single case limits generalizability and cannot establish causality.
- Lack of confirmatory biomarkers for serotonin toxicity and limited long-term follow-up.
Future Directions: Aggregate case series to characterize neuromuscular complications after TCA overdose and prospective surveillance for ARDS/CIP in toxicologic ICU cohorts.
We report the case of a patient who ingested a lethal dose of amitriptyline, presented with serotonin syndrome-like neurological symptoms on arrival, and subsequently developed suspected critical illness polyneuropathy (CIP) during the clinical course. A 54-year-old man with a history of depression intentionally ingested approximately 2,250 mg of amitriptyline in a single dose. On arrival, he exhibited altered consciousness, hyperthermia, metabolic acidosis, and QRS prolongation, necessitating the immediate initiation of mechanical ventilation and intravascular cooling. Despite sedation, myoclonus emerged, raising suspicion of serotonin syndrome based on the presence of hyperthermia, myoclonus, and altered mental status. Clonazepam, levetiracetam, and cyproheptadine were administered, along with alkalinization therapy. During hospitalization, the patient developed aspiration pneumonia that progressed to acute respiratory distress syndrome, requiring prone positioning and prolonged mechanical ventilation. Profound respiratory muscle weakness necessitated tracheostomy. Subsequently, limb weakness and nerve conduction study findings raised suspicion for CIP. This case highlights that tricyclic antidepressant intoxication can manifest with diverse neurological and neuromuscular complications, necessitating comprehensive management from the acute through chronic phases.