bluuebunny/crossref_metadata_2025 huggingface dataset:
Cluster randomised crossover trials with binary data and unbalanced cluster sizes: Application to studies of near-universal interventions in intensive care
Authors: Forbes Andrew B , Akram Muhammad , Pilcher David , Cooper Jamie , Bellomo Rinaldo
Published: December 2014

Background:

Cluster randomised crossover trials have been utilised in recent years in the health and social sciences. Methods for analysis have been proposed; however, for binary outcomes, these have received little assessment of their appropriateness. In addition, methods for determination of sample size are currently limited to balanced cluster sizes both between clusters and between periods within clusters. This article aims to extend this work to unbalanced situations and to evaluate the properties of a variety of methods for analysis of binary data, with a particular focus on the setting of potential trials of near-universal interventions in intensive care to reduce in-hospital mortality.

Methods:

We derive a formula for sample size estimation for unbalanced cluster sizes, and apply it to the intensive care setting to demonstrate the utility of the cluster crossover design. We conduct a numerical simulation of the design in the intensive care setting and for more general configurations, and we assess the performance of three cluster summary estimators and an individual-data estimator based on binomial-identity-link regression.

Results:

For settings similar to the intensive care scenario involving large cluster sizes and small intra-cluster correlations, the sample size formulae developed and analysis methods investigated are found to be appropriate, with the unweighted cluster summary method performing well relative to the more optimal but more complex inverse-variance weighted method. More generally, we find that the unweighted and cluster-size-weighted summary methods perform well, with the relative efficiency of each largely determined systematically from the study design parameters. Performance of individual-data regression is adequate with small cluster sizes but becomes inefficient for large, unbalanced cluster sizes. When outcome prevalences are 6% or less and the within-cluster-within-period correlation is 0.05 or larger, all methods display sub-nominal confidence interval coverage, with the less prevalent the outcome the worse the coverage.

Limitations:

As with all simulation studies, conclusions are limited to the configurations studied. We confined attention to detecting intervention effects on an absolute risk scale using marginal models and did not explore properties of binary random effects models.

Conclusion:

Cluster crossover designs with binary outcomes can be analysed using simple cluster summary methods, and sample size in unbalanced cluster size settings can be determined using relatively straightforward formulae. However, caution needs to be applied in situations with low prevalence outcomes and moderate to high intra-cluster correlations.
President's Report
Authors: Ridley Saxon
Published: December 2014

My first and most pleasant duty as the incoming President is to thank my predecessor. Peter worked extremely hard for the Society and, with a considered and measured response to all problems and challenges, proved to be an extremely safe pair of hands guiding the Society. While the Society's main roles are to further education and research, the Society is asked to comment on a wide range of critical care issues. Peter always ensured that the Council's response was formulated after canvassing of as many views as possible and reasoned deliberation. Peter made sure that the Society avoided short-term satisfaction for the better goals of longer-term gain. I know he is looking forward to a well-earned relative rest as immediate past president. No doubt he has some new challenges in mind.
Trainee Division Survey of Working Patterns, Training and Education
Authors: Ford Peter , McAuley Danny F
Published: December 2014

This article summarises the results of a survey which was sent out in 2002, just prior to the CCST in intensive care medicine (ICM) being approved. It focused on the information received by trainees regarding ICM training and their feelings on different working patterns.
ICS Spring Meeting 2003
Authors: Buglass Helen
Published: December 2014

The annual spring ICS meeting was held this year at the Harrogate International Centre in Yorkshire. Four hundred and fifty delegates attended the three days.
Evidence-Based Intensive Care-The Scottish Medium
Authors: Cairns Chris , Daniel Malcolm
Published: December 2014

Oh no not another article about evidence-based medicine (EBM)! Half of you are thinking ‘it's marvellous and tells you exactly the best way of managing your patients’. The other half if you have read this far will be thinking ‘not more EBM — yet again it's someone trying to replace common sense and experience’.
The Development and Analysis of a Database to Record Critical Incidents Associated with Intravenous Drug Administration in Critically III Patients
Authors: Thomas AN , Boxall EM , Sabbagh G , Eddleston J , Dunne A , Stevens A , Murphy P
Published: December 2014

Staff were asked to report critical incidents associated with intravenous medications across a critical care network. These were categorised using a database by drug and drug class, seriousness and level of harm, process stage and communication factors. 139 critical incidents were identified in 3848 patient days. Noradrenaline, omeprazole, gentamicin and insulin were most commonly involved (range 6 to 9 incidents). Twenty two incidents involved drug supply, 61 prescriptions, 10 preparation and 58 administration.

The use of a structured database allowed a clearer understanding of incidents to be established and we make some recommendations to improve safety. The classification database could be established across many intensive care units to improve understanding of incidents associated with intravenous medications.
Critical Care Contingency Planning: Phased Responses and Triaging Framework
Authors: Taylor Bruce , Kemp Verity , Goldhill David , Waldmann Carl
Published: December 2014

As most of our readers will be aware from previous publications and from the special articles contained in this edition, a lot of work has gone into highlighting the implications of an influenza pandemic for critical care services and trying to work out how to make the best use of the resources that may be available. The latest Department of Health Document ‘Pandemic influenza: surge capacity and prioritisation in health services – provisional UK guidance’ (available on the DH website) has made an encouraging start in providing official recognition of the problems likely to be encountered as a result of limited bed capacity, and also supports the concept that triaging decisions cannot be left to secondary care (and particularly critical care specialists) alone. Regrettably, however, even if its recommendations for patient selection are fully followed and the number of inappropriate referrals to critical care is reduced significantly, there is still a strong probability that during the peak of a pandemic the number of patients who are likely to benefit from critical care will still significantly exceed bed capacity – even if this is maximally expanded.

In the original working of the Critical Care Contingency Planning Group a draft document on Phased Responses and Triaging was produced as a starter to addressing these difficulties. Further work on this was then put on-hold pending the production of official ethical guidance and other documentation to address these problems. However, now that these have been finalised and we still face potential dilemmas about how ICUs will be able to cope, feedback from critical care network discussions has persuaded us that it may be useful to circulate a revised version of this document, updated to include more recent recommendations, in the hope that this may be of help in assisting local planning.

In particular, the document addresses two concepts that were initially felt to be inappropriate or unacceptable, but which now may be considered reasonable/realistic. These are the possibility of using some method of lottery selection if there are several appropriate referrals but insufficient bed numbers, and the fact that at some point there may be a requirement to accept temporary closure of intensive care to further referrals if no beds are available. It is hoped that consensus support for the principles of this document may help to produce reassurance for staff (with the support of local PCTs and Trust Management) that if potentially preventable deaths occur in such circumstances they will not be vulnerable to litigation or professional criticism when no other treatment options were available.
Association between Cardiac Index and Mortality in Patients Assessed on the Ward by a Nurse-Led Critical Care Outreach Team
Authors: Nourse Simon , Hurding Alan , McGinley Ann , Mandersloot Gerlinde , Pearse Rupert
Published: December 2014

Derangements in cardiac output are associated with mortality in various patient groups but the relationship between cardiac output and mortality in critically ill patients on standard hospital wards has not been investigated. In this single-centre observational study, cardiac output was measured using a non-invasive supra-sternal Doppler technique in patients referred to a critical care outreach team. Data were collected at baseline and four hours later in 113 patients, of whom 28 died (24.8%) and 37 were admitted to critical care (32.7%). During this period, there was a significant decrease in mean cardiac index (2.74 L/min/m2 [95% confidence intervals 1.78–4.35] to 2.18 L/min/m2 [95% CI 1.54–3.21]; p=0.049) and stroke volume index (24 mL/m2 [95% CI 16–36] to 20 mL/m2 [95% CI 15–31]; p=0.02) in non-survivors, whilst in survivors these variables remained unchanged. There were no changes in heart rate or mean arterial pressure in either survivors or non-survivors. For 216 patients in whom only baseline data were available, only age, heart rate, arterial pressure, respiratory rate and temperature were independently associated with mortality. In conclusion, in the four hours following assessment on the ward by a critical care outreach team, cardiac index and stroke volume index were maintained in survivors, but decreased significantly in non-survivors. At baseline, neither variable was associated with mortality.
Surviving Sepsis beyond Intensive Care: A Retrospective Cohort Study of Compliance with the International Guidelines
Authors: Simmonds Mark , Hutchinson Andrew , Chikhani Marc , Bewick Tom , Meyer Joel , Davies Sian , Morris Craig
Published: December 2014

The early recognition and goal-directed management of severely septic patients has been shown to reduce mortality. This study aimed to determine compliance with the ‘Surviving Sepsis' guidelines and to analyse the systems involved in delivering care in a UK teaching hospital. Patients from any hospital department with clinically significant positive blood cultures (n=229) were identified. Adults who met criteria for severe sepsis and who were deemed suitable for active management were included (n=46). None of the patients received all bundle elements within the advised time limits. Only 52% had received broad-spectrum antibiotics within three hours of presentation and only 57% had adequate fluid resuscitation within six hours. The median time from presentation to doctor involvement was 1.1 hours, with a delay of 3.9 hours to see a senior clinician. The median time from presentation to admission to the high dependency unit (HDU) or intensive care unit (ICU) was 12.9 hours. This study has shown that the early recognition and resuscitation of septic patients is unreliable and the capacity to provide early antimicrobial and goal-directed therapy for septic patients is limited in a UK teaching hospital.
Assistance with Anaesthetic Interventions outside the Intensive Care Unit: Results from a National Survey of Practice and of Medical Staffing
Authors: Allan Charlotte G , Cross Matthew E , Cook Caroline J
Published: December 2014

We undertook a web-based survey of intensive care units (ICUs) in England, Wales and Northern Ireland in order to deter-mine which groups of healthcare professionals were routinely being used to assist with stabilisation of critically ill patients outside the ICU. We also investigated what support was immediately available to patients with acute airway problems on the units themselves. We found that assistants often lack the training required to safely assist the ICU doctor. Out of hours, almost 38% of hospitals use under-skilled assistants during emergency intubations. Over 50% of units rely on theatre anaesthetists or non-resident consultants for emergency airway support if the ICU doctor is not available. To ensure patient safety, formal guidelines should be introduced at national and local levels to identify who should be assisting with stabilisation of critically ill patients and what level of training they should receive. This should be subject to regular audit.
Physical Rehabilitation following Critical Illness
Authors: Baker Catherine , Mansfield Leigh
Published: December 2014

The effects of critical illness and associated significant periods of immobility often result in patients requiring lengthy periods of rehabilitation. Patients frequently have diminished cardiac and respiratory reserve, together with generally decreased muscle strength and endurance. Myopathies and neuropathies are sometimes evident, and patients are frequently unable to carry out simple functional tasks.

Although the need for physical rehabilitation is well established, substantive evidence to guide rehabilitation services is lacking. Research has been conducted to establish safe commencement of mobilisation, and expert opinion is that there is a generally accepted hierarchy of mobilisation techniques. As well as progressively increasing mobility, there are also suggestions that specific exercise programmes can influence weaning time and length of stay. Post discharge, evidence suggests that there is a need for on-going rehabilitation, and early research shows encouraging results. However, many questions remain unanswered. More evidence is required in order to establish what the best practice is for acute rehabilitation and for rehabilitation as part of follow-up care.
Necrotising Pneumonia, Staphylococcus Aureus and Panton-Valentine Leukocidin
Authors: McGrath Brendan , Rutledge Fionna , Broadfield Emma
Published: December 2014

The Panton-Valentin leukocidin (PVL) strain of meticillin-resistant Staphylococcus aureus (MRSA) is producing a new pattern of MRSA-related disease in the UK and world-wide. PVL is one of several extracellular cytotoxins produced by Staphylococcus aureus, and is usually associated with skin and soft tissue infections. PVL MRSA is uncommon in hospitals, but in the US, and now in the UK, there have been reports of severe, rapidly progressive, community-acquired haemorrhagic, necrotising pneumonia occurring in previously healthy young adults, and associated with a mortality rate of up to 75%. We review features of the pathophysiology, diagnosis and treatment of this condition, whose incidence appears to be increasing in the UK.
What is the Health-Related Quality of Life of Patients with Chronic Obstructive Pulmonary Disease after Invasive Ventilation?
Authors: de Beer T
Published: December 2014

Patients with chronic obstructive pulmonary disease (COPD) make up a large proportion of hospital in-patients; they account for 12% of general medical admissions. Decisions to ventilate a patient with an exacerbation of COPD are partly based on the physician's prediction of future quality of life. In this systematic review, Pubmed, Medline, Embase, Biomed Central and the Cochrane library were electronically searched for observational and interventional studies of health-related quality of life (HRQoL) in patients with COPD, who were invasively ventilated, survived to hospital discharge and were followed up for HROoL measurements to be made. The results of the nine studies included showed that HROoL does deteriorate after invasive ventilation in intensive care, but is similar to that of patients who are on long-term oxygen therapy (LTOT) or in pulmonary rehabilitation programmes. Despite the high long-term mortality of patients with COPD, the HROoL in patients who do survive is reasonable. Identifying these patients remains a significant challenge.
The Influence of the Corticus Study on Steroid Use for Septic Shock in Scottish Intensive Care Units
Authors: Cuthill Jennifer A , Brett Michael
Published: December 2014

The publication of the CORTICUS study in January 2008 suggested that the use of low-dose steroids in patients with septic shock did not improve survival or reversal of shock. This result contradicted results from the original trial by Annane in 2002. We carried out a telephone survey of all the intensive care units in Scotland eight weeks following the publication of the CORTICUS study, with the aim of assessing any change in practice since its publication. Prior to CORTICUS, 62% of Scottish intensive care units prescribed steroids routinely in all patients with septic shock requiring vasopressors. Eight weeks following the publication of CORTICUS, only six (25%) units had changed or planned to change their practice. Despite this relatively small change, 50% of the medical staff we questioned claimed that the CORTICUS study had affected their own individual practice.
A Preliminary Audit of Interruptions in Intensive Care: Implications for Patient Safety
Authors: Nimmo Graham R , Mitchell Claire
Published: December 2014

Interruptions occur throughout clinical practice. They occur during ward rounds, procedures, discussions with relatives or specialists, while checking drugs or equipment, when prescribing and writing in notes. They can take the form of face-to-face interaction, telephone calls or text messages, pagers, alarms on monitors or equipment. They may be for mundane reasons, low priority or urgent. They may be for relaying information, to refer patients, to discuss plans, to arrange treatment or investigations. Some are unnecessary and potentially unsafe, but others are essential re-directions to more urgent clinical situations. It may be that educational interventions could be used to reduce the detrimental effects of ill-timed interruptions and to promote effective re-directional interruptions.
Selenium in Critically Ill Patients
Authors: Strachan Stephanie , Wyncoll Duncan
Published: December 2014

There is increasing evidence that particular nutritional substrates may be important in critically ill patients and in recent years there has been growing interest in selenium. This review aims to outline the incidence of selenium deficiency in critically ill patients, the consequences of such a deficiency and present the evidence for, and effect of, selenium supplementation in these patients. Selenium levels fall during periods of oxidative stress as occurs in critically ill patients with conditions such as severe sepsis, burns, and following trauma. Data from individual studies and meta-analyses suggests that selenium is an important adjuvant therapy in certain critically ill patients and supplementation of selenium may offer a mortality benefit.
The Role of Hypotensive Resuscitation in the Management of Trauma
Authors: Jackson Kathryn , Nolan Jerry
Published: December 2014

The primary objective of trauma care is to minimise or reverse shock thus saving life. Aggressive fluid resuscitation may be harmful in these patients because the resulting increased blood pressure and circulating volume may cause clot disruption, dilution of clotting factors and/or the reversal of the body's natural response to haemorrhage. The concept of hypotensive resuscitation has evolved where small aliquots of fluid are infused, with hypovolaemia and hypotension tolerated as a necessary evil until definitive haemorrhage control can be achieved. This review outlines the animal and human data to support the strategy of hypotensive resuscitation.
The Problems Diagnosing Ventilator-Associated Pneumonia
Authors: Stewart Neil I , Cuthbertson Brian H
Published: December 2014

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in the intensive care unit. Clinical, radiological and microbiological criteria are used to make the diagnosis, but there is no consensus definition, as no individual criterion or combination of criteria offer sufficient diagnostic accuracy to support their sole use in defining VAP. Neither invasive bronchoscopic sampling nor less invasive quantitative tracheal aspirate, conveys an advantage when making the microbiological diagnosis of VAP. Of the scoring systems and definitions presently in use, the Clinical Pulmonary Infection Score (CPIS) has been shown to be prone to inter-observer variability; the US Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) definition relies heavily on subjective clinical criteria, and the Hospitals in Europe Link for Infection Control through Surveillance (HELICS) criteria employ similarly subjective clinical criteria with five different possibilities for microbiological diagnosis. The use of these different diagnostic methods leads to marked variation in the reported incidence of VAP. Clinical practice requires an objective and transferable definition for VAP so that we can improve the reporting, monitoring and treatment of VAP.
Insertion of Post-Pyloric Feeding Tubes in the ICU is Not as Difficult as we Thought
Authors: Swinton Frank , Donovan Kate , White Nigel
Published: December 2014

Post-pyloric feeding has been shown to be beneficial compared to gastric feeding in terms of calories delivered, length of intensive care unit stay and possibly rates of ventilator-associated pneumonia and mortality. It has often been disregarded as taking too long or requiring expensive equipment, but we have established a rapid, safe, cheap and reliable technique for inserting post-pyloric feeding tubes.
The Treacherous Clot: Arterial Line External Haematoma in a Patient with HIT While Receiving Lepirudin
Authors: Nandalan Subash
Published: December 2014

Heparin-induced thrombocytopenia is known to produce thrombotic events in addition to bleeding. A large external haematoma developed around the radial arterial line site in a patient with proven HIT while receiving lepirudin. The haematoma masqueraded as continued bleeding and delayed starting renal replacement therapy. This case emphasised the importance of close visual examination of intravascular catheter sites for any evidence of thrombosis.
High Intensity Continuous Renal Replacement Therapy does not Improve Mortality in Critically Ill Patients
Authors: Hornsby J
Published: December 2014

In critically ill patients with acute kidney injury, high intensity continuous renal replacement therapy (CRRT) (effluent flow rate >25mL/kg/h) shows no benefit on 90-day mortality and is associated with more hypophosphataemia.

Level of evidence: 1+ (RCT with a low risk of bias)
Advances in Postresuscitation Care
Authors: Yeung Joyce , Couper Keith , Giles Simon , Perkins Gavin D
Published: December 2014

A co-ordinated, evidence-based approach to treatments following cardiac arrest can have a significant impact on outcome. In comatose survivors of cardiac arrest, therapeutic hypothermia (temp 32–34°C) should be induced as soon as possible and maintained for 12–24 hours before controlled rewarming. Cardiac impairment is usually transient and responds to fluids and vasopressors/inotropes. Aim for a mean arterial blood pressure to achieve adequate end organ perfusion. Patients with a suspected cardiac cause of their arrest should be considered for angiography with or without percutaneous transluminal coronary angioplasty (PTCA). Hyperglycaemia should be treated with insulin. Controlled ventilation should aim for oxygen saturations of 94–96% and normocapnia. Prognostic tests are unreliable initially and should be deferred until at least 72 hours following return of normothermia.
Depth of Intraparenchymal Brain Monitoring Devices in Neurosurgical Intensive Care
Authors: Ross Mark J , McLellan Stuart A , Andrews Peter JD
Published: December 2014

The Brain Trauma Foundation guidelines recommend intracranial pressure (ICP) monitoring for the majority of patients with severe traumatic brain injury. ICP monitors have therefore become an integral part of the intensive care management of these patients however such invasive devices are not without risk. Following a critical incident in which an intraparenchymal cerebral perfusion catheter was inserted significantly further than intended, we undertook a retrospective audit of the depth of intraparenchymal brain monitoring devices in patients with traumatic brain injury and subarachnoid haemorrhage. The majority of intraparenchymal monitoring devices were ICP catheters and the majority of these were inserted beyond the manufacturers' recommendations despite most of these catheters having an integral depth indicator. Extreme care should be taken when inserting monitors that do not have a depth indicator.
Primary Clostridium Difficile Spinal Epidural Abscess
Authors: Champaneria Nilesh , Goonesekera Harinda , Shippey Ben
Published: December 2014

A 64-year-old woman presented to the emergency department, agitated and confused with a history of back pain, alcoholic cirrhosis and previous drainage of a neck abscess. She developed clonic-tonic seizures and was referred to intensive care. She was intubated and a lumbar puncture yielded pus with Clostridium difficile grown on culture. MRI scanning revealed an epidural abscess with evidence of discitis. The authors speculate on the origin of the infection and review the presentation of epidural abscess.
Fatal Poisoning with Glyphosate-Surfactant Herbicide
Authors: Beswick Eleanor , Millo Julian
Published: December 2014

A 29-year-old man was admitted following deliberate ingestion of approximately 300 mL of ‘Roundup Ace,’ a herbicide containing glyphosate. On presentation, he was agitated and required intubation and admission to ICU. He developed severe and persistent lactic acidosis, hyperkalaemia, hypotension, torrential watery diarrhoea and abdominal distension in the first 24 hours. The patient was supported with a continuous noradrenaline infusion and continuous veno-venous haemodiafiltration. The clinical course was further complicated by cardiac arrhythmias and an episode of cardiac arrest. By day three, he had bone-marrow, liver and worsening respiratory failure. There was no hope of recovery; therefore, noradrenaline was discontinued, and the patient died 15 minutes later. Glyphosate-surfactant herbicide (GlySH) is a general-purpose herbicide with no anticholinesterase effect and no organophosphate-like CNS effects. GlySH intoxication has a case fatality rate of between 3.2% and 29.3%. There is no antidote and the mainstay of treatment for systemic toxicity is decontamination and aggressive supportive therapy. Early renal replacement therapy may improve prognosis but there is no evidence to support this. There is one published case of a patient who survived severe GlySH poisoning following administration of intravenous fat emulsion. Glyphosate-surfactant herbicide, commercially known as ‘Roundup’ is a widely available herbicide commonly used in both professional and domestic settings. This is a case of a young man who deliberately ingested GlySH at home and rapidly developed multi-organ failure, culminating in his death.
Report of the NAP4 Airway Project
Authors: Cook Tim , Harper Jane , Woodall Nick
Published: December 2014

Major complications related to airway management over a 12-month period were reported and examined by an expert panel in the Royal College of Anaesthetists' fourth National Audit Project. Thirty-six reports originated in the intensive care unit, just under 20% of all reports, but resulted in 60% of deaths or significant neurological injury of all cases examined. Cases could be broadly divided into: failed or unrecognised oesophageal intubation; airway displacement; haemorrhage; airway problems during patient transfer; and other. Capnography was not used routinely and contributed to delayed recognition of airway problems. Staff managing complex airways did not always have advanced airway skills. Equipment and back-up planning was frequently deficient. The panel have made recommendations to attempt to improve airway management in the intensive care environment.

This article is a précis of two chapters (chapter 9, Intensive care; and chapter 15, Major airway events in patients with a tracheostomy) in the NAP4 audit report. The complete report is available as referenced below.1 The British Journal of Anaesthesia has also published a report of airway events in intensive care and emergency departments from NAP4.2
The Outcomes of Adult Patients with Haematological Malignancy Requiring Admission to the Intensive Care Unit
Authors: McDowall Katherine L , Hart Alistair J , Cadamy Andrew J
Published: December 2014

A literature review was conducted to ascertain the prognosis of patients with haematological malignancies admitted to the intensive care unit (ICU) and to identify any factors that could be shown to influence outcome. Studies that examined outcomes among patients with haematological malignancy admitted to ICU were evaluated. Pooled outcome data relating to ICU, hospital and six-month mortality were compiled. A qualitative assessment of the evidence relating to putative determinants of prognosis was made. Observational studies examining outcomes among over 10,000 haematological malignancy patients admitted to the ICU were identified. Approximately 40% of such patients survived until hospital discharge. The principle determinants of short-term survival would appear to be related to the severity of the acute illness and the consequent physiological derangement or organ system dysfunction. In the longer term, factors relating to the prognosis of the underlying malignancy appear to be important.
Use of LMA during Percutaneous Tracheostomy
Authors: Pratt Tom , Bromilow James
Published: December 2014

During percutaneous tracheostomy in a predominantly neurosurgical ICU population, ventilation using a laryngeal mask airway compared to an endotracheal tube, was associated with an improved visulisation of the intratracheal structures.

Level of evidence: 1+ (RCT with a low risk of bias)
Functional Disability 5 Years after Acute Respiratory Distress Syndrome
Authors: Ramaiah Ravi S , Kirk-Bayley Justin
Published: December 2014

This prospective, longitudinal study is an extension of the seminal work by Herridge,1 which sheds light into the physical and psychological impairment, and the increased costs of healthcare services associated with critical illness following survival from acute respiratory distress syndrome (ARDS). This benchmark paper stresses the need for family-centred, long-term rehabilitation after a prolonged critical illness.

Level of evidence: 2C (Outcome/follow-up study)
The use of Ultrasound Imaging Prior to Percutaneous Tracheostomy
Authors: Mir Fauzia Ahmad , Hopkins Philip , Holland Christopher , Ramnarine Raymond , Wan Ming Young Simon
Published: December 2014

Ultrasound scanning (USS) is commonly used in intensive care units (ICUs) for vascular access procedures, and for pleural and cardiac imaging. However, it is not routine practice to use USS prior to or during percutaneous tracheostomy. We report the case of a patient who was scheduled to have a percutaneous tracheostomy which was abandoned following assessment with ultrasound.
Paracetamol use and High Anion Gap Metabolic Acidosis
Authors: McGregor Andrew K , Laight Nicola S , Nolan Stephen
Published: December 2014

Accumulation of 5-oxoproline (pyroglutamic acid) has been reported as a rare cause of high anion gap metabolic acidosis. Chronic paracetamol ingestion in a susceptible individual can lead to accumulation of 5-oxoproline and a high anion gap metabolic acidosis. The condition resolves with supportive care and discontinuation of paracetamol and, most importantly, it can be prevented. This case report aims to alert clinicians to the condition as well as provide insight into the underlying mechanisms of the disease process. We report two cases of high anion gap metabolic acidosis due to accumulation of 5-oxoproline. Both patients had a recent history of regular paracetamol use for back pain on a background of poor nutrition. Common causes of high anion gap metabolic acidosis were excluded in both patients systematically. The underlying cause was discovered on testing for urinary 5-oxoproline. Both patients improved and the acidosis resolved upon withdrawal of paracetamol and other supportive measures. The need for a high index of suspicion and a detailed patient drug history is highlighted in these case reports, as raised anion gap metabolic acidosis is a common finding in critically ill patients. When lactate and ketones are absent, 5-oxoproline levels should be tested in patients who are taking paracetamol; especially in those who are malnourished or have other predisposing factors to reduced glutathione levels. Once suspected, paracetamol should be stopped, full supportive care should be initiated and treatment with N-acetylcysteine considered.
Aerolised Salbutamol in Acute Lung Injury
Authors: Pourkashanian Araz , Sachdeva Rajneesh , Johnston Andrew McD , Tunnicliffe Bill
Published: December 2014

Aerosolised salbutamol does not improve clinical outcomes in patients with acute lung injury.

Level of evidence: 1B (Individual RCT with a wide confidence interval)
Recurrent Acute Severe Pulmonary Oedema as a Presentation of Carcinoid Crisis following Cardiac Surgery
Authors: Shah Akshay , Panchatsharam Selvakumar , Ashley Elizabeth
Published: December 2014

This is a case report of a 75-year-old patient with a pelvic carcinoid tumour who had valve replacements and a patent foramen ovale repair. Her postoperative course was complicated by persistent symptoms related to the carcinoid tumour. Pathophysiology and management are reviewed. Cardiac surgery for carcinoid heart surgery has significantly high morbidity and mortality. Common complications include cardiovascular instability, bronchospasm, complete heart block, gastrointestinal hypermotility and acute kidney injury. Acute pulmonary oedema can be a presenting feature of a carcinoid crisis and should be suspected in the differential diagnoses of pulmonary oedema in carcinoid heart disease patients. Octreotide remains the mainstay of treatment. Doses of up to a maximum of 200 μg/hour can be used. There is emerging evidence that catecholamines can be used safely when used in conjunction with octreotide. Good analgesia is important in suppressing sympathetic stimulation.
Antibiotic Resistance Mechanisms in the Intensive Care Unit
Authors: Hatcher James , Dhillon Rishi , Azadian Berge S
Published: December 2014

Antibiotic resistance is increasingly recognised as a major threat to global health, with few new antimicrobial agents in development. The intensive care unit provides a unique environment for the growth and spread of drug-resistant organisms. Knowledge of the pathogenesis and mechanisms of resistance of drug-resistant organisms provides a conceptual framework which underpins the clinical manifestation of infections caused by these organisms, and is crucial for the intensivist to understand. Particular importance lies in the prevention of infection and the control of drug-resistant pathogens. The major resistance mechanisms of these organisms will be highlighted, focusing on specific gram-positive (meticillin-resistant Staphylococcus aureus and glycopeptide-resistant Enterococci), gram-negative ( Pseudomonas aeruginosa, Acinetobacter baumannii and multi-drug resistant Enterobacteriaceae) organisms, and then placed in historical and clinical context.
Does the Bispectral Index Monitor have a Role in Intensive Care?
Authors: Bigham Colin , Bigham Sarah , Jones Chris
Published: December 2014

Analysis of brain electrical activity is a method of assessing brain function. Interpreting the electroencephalogram is specialist and time-consuming. The bispectral index score (BIS) processes the EEG into manageable numbers. BIS was programmed on healthy individuals undergoing general anaesthesia and used to reduce the incidence of awareness. In the ICU, BIS has been investigated to assess sedation, to induce burst suppression, as a tool to provide early prognosis after brain injury and in scheduling timing for brain stem testing. From these investigations, the following conclusions may be drawn. BIS may be used to prevent both awareness and over-sedation in ICU in appropriate clinical settings. Inducing burst suppression in patients with refractory status epilepticus can be achieved by targeting BIS less than 30, although BIS appears to be an unreliable method for detecting breakthrough epilepsy. BIS less than 22 after anoxic brain injury may have a high likelihood to predict poor outcome, however false positives occur. Despite studies suggesting that BIS might be a useful monitor to prevent secondary brain injury and provide early prognostic information, the sensitivity and specificity are not high enough to be clinically reliable. Currently, clinical decisions made on the basis of BIS monitoring in the ICU should be limited to providing appropriate sedation, eg during neuromuscular blockade, and to providing feedback on induced burst suppression when continuous EEG is not available. Even in the latter situation, it is advisable to check correlation with a formal EEG.
Severe Adenovirus Infection: An Under-Recognised Disease with Limited Treatment Options
Authors: Houlihan Catherine , Valappil Manoj , Waugh Sheila , Cantlay Kaye , Price D Ashley , Dhillon Rishi H-P
Published: December 2014

Severe adenovirus infections can occur in both immunocompromised and immunocompetent patients. New serotypes are emerging in the UK, and should be considered in patients who present with respiratory tract symptoms and no other obvious pathogen. The difficulties of diagnosis and treatment of severe adenovirus infection are discussed.
Partial Anomalous Pulmonary Venous Drainage – ‘Where's my Line?’ and ‘Can I Use it?’
Authors: Burrows Tamzin , Sansom Hugh , Law Robert , Taylor Andrew , Lewington Andrew
Published: December 2014

This case report describes a patient with previously undiagnosed congenital partial anomalous pulmonary venous drainage, admitted to the intensive care unit in extremis. A catheter inserted for renal replacement therapy was placed in an unusual position but used successfully for dialysis.
Pulmonary Embolism in the Mechanically-Ventilated Critically Ill Patient: Is it Different?
Authors: Zochios Vasileios A , Keeshan Alex
Published: December 2014

Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
Hydroxyethyl Starch 130/0.42 versus Ringer's Acetate in Severe Sepsis
Authors: Taylor Matthew George , Bromilow James
Published: December 2014

Using hydroxyethyl starch (HES) 130/0.42 instead of crystalloid for fluid resuscitation of adult intensive care patients with severe sepsis increases mortality.

Level of evidence: 1B (RCT with narrow confidence intervals)
Evaluation of Noise Levels in Intensive Care Units in Two Large Teaching Hospitals – A Prospective Observational Study
Authors: Padmakumar Anand D , Bhasin Victoria , Wenham Timothy N , Bodenham Andrew R
Published: December 2014

Critically ill patients do not sleep well. One of the major environmental factors influencing sleep is noise. We prospectively measured noise levels and their relation to the time of day and location in different parts of two separate intensive care units (ICUs). Maximum, minimum and average noise levels were collected over 24 hour periods on five random days in both ICUs using digital sound meters, measured by the A-weighted decibel scale (dB (A)). The World Health Organisation (WHO) recommends that the average background noise in hospitals should not exceed 35 dB (A), and that peaks during the night should be less than 40 dB (A). The measured noise levels in both ICUs were well above the WHO standards. We recommend that various aspects, including staff education and modification of ICU design, must be carefully considered to provide an optimum environment for critically ill patients.
Serious Hazards of Transfusion (SHOT): Its Implications for Intensive Care
Authors: Mugabe Benias , Thomas Dafydd , Bolton-Maggs Paula , Cohen Hannah
Published: December 2014

SHOT has reported serious hazards of transfusion since 1996. This paper reviews some of the major complications related to transfusion such as transfusion-related acute lung injury, transfusion-associated circulatory overload, transfusion-associated dyspnoea and acute and haemolytic transfusion reactions. Both under-use and over-use of blood and blood components have been reported and the authors emphasise the importance of education in proper use of this resource. The optimal trigger for transfusion in the critically ill is still unknown.
Survey on the Use of Gentamicin and Vancomycin in Adult Intensive Care Units
Authors: Gopal Vijayakumar , Keane Melanie , Ail Dhiraj
Published: December 2014

Aminoglycosides and glycopeptides are frequently used as empirical antibiotics in critically ill patients. Various nomograms are employed to monitor and adjust doses either as once daily or more frequent regimens. However, there is no universal guidance for their administration and monitoring. We conducted a survey, using an online questionnaire, of adult intensive care units (ICUs) across England, Wales and Northern Ireland, to ascertain prescribing and monitoring practices. ICUs listed on the Intensive Care National Audit and Research Centre (ICNARC) register were invited to participate. A total of 242 intensive care units were approached and 24.3% responded (n=59). Of those responding, 100% (n=59) used gentamicin to treat gram-negative infections, with 96.6% (n=57) of them using a once daily regimen and 11.9% (n=7) using multiple doses daily. An initial gentamicin dose of 5mg/kg was used by 53.4% (n=31), whereas 25.9% (n=15) used a concentration of 7 mg/kg. With regard to use of glycopeptides, vancomycin was used by 83.1% (n=49) of responders while 61% (n=36) used teicoplanin. Over two-thirds of responders (67.3%, n=35) indicated that they used vancomycin as an intermittent daily dose and 32.7% (n=17) used it as a continuous infusion. We conclude that diversity exists as to the use and monitoring of aminoglycosides and glycopeptides within the ICUs surveyed. Most of the clinicians stopped antibiotics based on clinical assessment rather than a predetermined duration (eg five days or seven days) and a small number of units used procalcitonin to guide antibiotic therapy.
Intensive Care and Rehabilitation — A Patient'S Perspective
Authors: White Catherine
Published: December 2014

Catherine White describes the experience of critical illness and recovery, through her own experiences and those of other former intensive care unit patients. She gives recommendations for units to improve the patient experience, emphasising the importance of follow up and support.
Transfusion Strategies for Acute Upper Gastrointestinal Bleeding
Authors: Balthazor David , Jefferson Oliver , Torlinski Tomasz
Published: December 2014

In patients with significant gastrointestinal haemorrhage, the use of a transfusion trigger of a haemoglobin level of 7 g/dL instead of 9 g/dL demonstrated a significant survival benefit (NNT 25) together with a significant reduction in rates of rebleeding, adverse events and use of blood products.

Level of evidence: 2B (non-blind, single centre RCT with a risk of bias)
Intensive Care in the Defence Medical Services
Authors: Hutchings Sam , Risdall Jane , Lowes Tim
Published: December 2014

Recent military operations have highlighted the role of the Defence Medical Services in the management of casualties with complex traumatic injury. This article outlines the provision of intensive care support during deployed operations.
Modern Protective Ventilation Strategies: Impact upon the Right Heart
Authors: Morris Craig GT , Burn Steven A , Richards Simon B
Published: December 2014

‘Protective ventilation’ for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) is a major advance in intensive care medicine. However, components of protective ventilation expose the right heart to challenges. Acute cor pulmonale (ACP), patent foramen ovale (PFO) and right ventricular failure (RVF) are recognised complications that could potentially reduce the benefit of protective ventilation. We sought to determine the rates of ACP, PFO and RVF in critically ill adults undergoing protective ventilation with ARDS/ALI and to identify their impact on mortality and critical illness acuity. A comprehensive search of electronic databases including Medline (OVID, EmBase) and CINAHL (EBSCO) was undertaken, including Cochrane Library and international registries, between January 1991 and December 2011. A systematic review identified a total of 248 articles; 27 were reviewed in full and 22 studies were included. All 22 included studies were observational or quasi-experimental with no randomised, controlled trials available. ACP was present in 16–100%, PFO 1.3–22.0% and RVF 9.6–26.0%. Neither ACP nor PFO was associated with an adverse effect on mortality and ACP seemed reversible in survivors; however both ACP and PFO were associated with prolonged need for ICU support. RVF was variously associated with no increase in mortality to an odds ratio 5.1 for death in multivariate analysis. There was marked heterogeneity in the studies included, explaining the range of observed values. Recommendations for future research and practice were produced. Modern protective ventilation during ARDS has been shown to exert inconsistent effects on the right heart which may be of clinical significance. Further research is needed to determine these effects better.