Background The COVID-19 pandemic has created ethical challenges for intensive care unit (ICU) professionals, potentially causing moral distress. This study explored the levels and causes of moral distress and the ethical climate in Dutch ICUs during COVID-19. Methods An extended version of the Measurement of Moral Distress for Healthcare Professionals (MMD-HP) and Ethical Decision Making Climate Questionnaire (EDMCQ) were online distributed among all 84 ICUs. Moral distress scores in nurses and intensivists were compared with the historical control group one year before COVID-19. Results Three hundred forty-five nurses (70.7%), 40 intensivists (8.2%), and 103 supporting staff (21.1%) completed the survey. Moral distress levels were higher for nurses than supporting staff. Moral distress levels in intensivists did not differ significantly from those of nurses and supporting staff. “Inadequate emotional support for patients and their families” was the highest-ranked cause of moral distress for all groups of professionals. Of all factors, all professions rated the ethical climate most positively regarding the culture of mutual respect,  ethical awareness and support. “Culture of not avoiding end-of-life-decisions” and “Self-reflective and empowering leadership” received the lowest mean scores. Moral distress scores during COVID-19 were significantly lower for ICU nurses (p < 0.001) and intensivists (p < 0.05) compared to one year prior. Conclusion Levels and causes of moral distress vary between ICU professionals and differ from the historical control group. Targeted interventions that address moral distress during a crisis are desirable to improve the mental health and retention of ICU professionals and the quality of patient care.

Introduction Intravenous (IV) fluid is a key intervention in the management of septic shock. The benefits and harms of lower versus higher fluid volumes are unknown and clinical equipoise exists. We describe the protocol and detailed statistical analysis plan for the Conservative versus Liberal Approach to fluid therapy of Septic Shock in the Intensive Care (CLASSIC) trial. The aim of the CLASSIC trial is to assess benefits and harms of IV fluid restriction versus standard care in adult intensive care unit (ICU) patients with septic shock. Methods CLASSIC trial is an investigator-initiated, international, randomised, stratified, and analystblinded trial. We will allocate 1554 adult patients with septic shock, who are planned to be or are admitted to an ICU, to IV fluid restriction versus standard care. The primary outcome is mortality at day 90. Secondary outcomes are serious adverse events, serious adverse reactions, days alive at day 90 without life support, days alive and out of hospital at day 90, and mortality, health-related quality of life, and cognitive function at 1 year. We will conduct the statistical analyses according to a pre-defined statistical analysis plan, including three interim analyses. For the primary analysis we will use logistic regression adjusted for the stratification variables comparing the two interventions in the intention-to-treat population. Discussion The CLASSIC trial results will provide important evidence to guide clinicians' choice regarding IV fluid therapy in adults with septic shock.

No abstract

We thank Niccoli et al for their letter, which interestingly suggested that intracoronary administration of abciximab may exert its action in patients with ST-segment elevation myocardial infarction through facilitation of reversible no reflow. Our study was designed to detect a difference in electrocardiographic and angiographic measures of immediate myocardial reperfusion after primary percutaneous coronary intervention, markers that are frequently used in medium-sized randomized studies and show strong correlation with clinical outcome. 1,2 In this regard, we did not include recovery of myocardial perfusion at a later time point as a prespecified end point. It is not our center's routine clinical practice to reevaluate the initial angiographic result and recovery of myocardial perfusion in the infarct-related artery before discharge, either by repeat angiography or by cardiac magnetic resonance imaging. Because the infarct-related artery may have been filmed in additional revascularization procedures only in highly selected cases, we believe that analysis of this small, nonprespecified subset of patients would not produce meaningful results. In fact, an early study has indicated that intracoronary administration of abciximab significantly reduced the primary end point of microvascular obstruction on cardiac magnetic resonance 2 days after primary percutaneous coronary intervention compared with intravenous administration. 3 Therefore, we agree with Niccoli et al that facilitation of reversible no reflow is one of the plausible mechanisms of action of intracoronary abciximab, a hypothesis that may be further tested in ongoing randomized studies on intracoronary versus intravenous abciximab administration that include cardiac magnetic resonance end points. 4 Rationale and design of the INFUSE-AMI study: a 2ϫ2 factorial, randomized, multicenter, single-blind evaluation of intracoronary abciximab infusion and aspiration thrombectomy in patients undergoing percutaneous coronary intervention for anterior ST-segment elevation myocardial infarction.

No abstract