bluuebunny/crossref_metadata_2025 huggingface dataset:
A Survey regarding Physician Preferences in End-of-Life Practices in Intensive Care across Scotland
Authors: McAree Simon James , Doherty Pamela Anne
Published: December 2014

Despite the large proportion of intensive care patients whose care is ultimately terminal, there is a lack of evidence to support best clinical practice caring for these patients. Ninety-seven consultants covering intensive care day sessions across Scotland were invited to take part in a web-based questionnaire. Fifty-eight respondents (60%) completed the questionnaire. Non-escalation of therapy and abrupt withdrawal appear to be the preferred methods of limiting treatment at the end of life. This was achieved most commonly by a reduction in FiO2 and cessation of inotropic support. Extubation was not favoured, with only four respondents claiming it as routine practice. Practical efforts made to determine futility appear to be made by at least two intensive care consultants. Of respondents, 24% consider non-escalation of treatment and active withdrawal to be ethically different and 15% held the view that there was moral equivalence between withdrawing treatment and the active shortening of the dying process. There are wide variations in clinician preferences for the methods used to limit treatment at the end of life. Consensus, therefore, may prove to be a challenge to achieve.
Neuroleptic Malignant Syndrome: Severe Hyperthermia Treated with Endovascular Cooling
Authors: Mathieu Steve , Hutchings Sam , Craig Gordon
Published: December 2014

We report a patient with neuroleptic malignant syndrome who presented with the characteristic features of altered mental state, hyperthermia, haemodynamic dysregulation, elevated creatine kinase and subsequently increased muscle rigidity. The hyperthermia was refractory to standard cooling techniques and dantrolene but was rapidly corrected using an endovascular cooling device. He recovered from this life-threatening condition but required ongoing renal replacement support following discharge from the intensive care unit.
The Introduction of an Oral Surgical Service in an Intensive Care Unit Serving a Deprived Inner City Population
Authors: Kearns Rachel , Brewer Andrew , Booth Malcolm
Published: December 2014

Much of the population of Glasgow has poor oral health. Poor oral hygiene is associated with the development of ventilator-associated pneumonia (VAP). In a survey of Scottish intensive care units (ICUs), none incorporated oral surgical review into their care. We evaluated the introduction of oral surgical review into our routine practice. An oral surgeon who was experienced in oral care provision in the critically ill reviewed patients who were expected to be mechanically ventilated for more than 48 hours. Oral health was assessed and interventions documented. One hundred patients were examined and forty-seven patients underwent oral surgical intervention. Thirteen patients required dental extraction. Of the patients not requiring additional oral care, 24/53 (45%) were edentulous. Our findings demonstrate that the oral care needs of this patient group were not being met by the current unit oral hygiene protocol. Further work is required to determine the optimal way to provide such a service cost effectively, and its impact on VAP prevention.
End-of-Life Care in Scottish Intensive Care Units
Authors: Dean Pamela , Labram Aileen , McCarroll Lynn , Hughes Martin
Published: December 2014

We wished to assess practice, staff attitudes and desire for change in the way dying patients are cared for in intensive care units (ICUs) in Scotland. A questionnaire was distributed to all 23 general ICUs in Scotland, for medical and nursing staff of all grades to fill in. A dying patient was defined as one in whom a decision had been taken to withdraw or withhold intensive care in the expectation that the patient would die in less than 12 hours; respondents first answered questions about current practice in their ICU, immediately followed by questions concerning ideal practice. The response rate was 62% with the majority of staff being satisfied with current practice, although even the respondents who were satisfied overall would significantly change delivery of care in some areas. A small number (<1%) would not reduce or stop ventilatory, cardiovascular or renal support. In this survey, the withdrawal and limitation of life-sustaining treatment in Scottish ICUs was common, but variable in practice. Institution of a common care pathway at the end of life would allow each unit to decide on the best process to facilitate high-quality end-of-life care, and have robust systems in place to ensure it is consistently delivered.
Commissioning and Contracting for Critical Care from 2011–12: Le ‘Payment by Results’ est Arrivé
Authors: Groves Jeremy
Published: December 2014

Payment by Results (PbR) is a system of paying for health care. It is linked to activity and adjusted for case-mix. This article explores the background to PbR for critical care, explains some of the terminology and looks at the implications of its planned introduction in 2011/12.
Transfer of the Critically Ill Adult: Building an Infrastructure for Wales
Authors: Farley-Hills Ed , O'Keeffe Sue
Published: December 2014

Transfer of the critically ill adult is an integral part of working life for intensive care staff in Wales and the rest of the UK. The numbers of inter-hospital transfers have been increasing year on year (approximately 550 last year) due to greater pressures on intensive care beds and greater specialisation at tertiary centres. Transfers have traditionally taken place in an ad hoc way with poor co-ordination between the stakeholders. In the North Wales Critical Care Network (NWCCN), holistic steps have been taken to improve the service and have succeeded in making the process of transfer safer. Although this work has been led by the network, it has been approached in a collaborative way working closely with the South East Wales Network (SECCN) and the Mid- and West- Wales Network (MWCCN), as well as the Welsh Ambulance Service, Welsh Air Ambulance and the Royal Air Force search and rescue. This article describes the process.
Post-Traumatic Stress Disorder in ICU Survivors
Authors: Jones Christina
Published: December 2014

Post-traumatic stress disorder (PTSD) may develop after exposure to a life-threatening event or serious injury. Symptoms include recurring and intrusive memories, such as flashbacks, avoidance of reminders and persistent symptoms of anxiety or physiological arousal. Many factors are associated with the development of PTSD in intensive care unit (ICU) patients, including increased length of stay, and greater levels and longer duration of sedation. Patient-related factors associated with a higher risk of PTSD include younger age, female gender, previous psychological problems and recall of delusional memories from ICU. In contrast, the formation of even fragmented factual memories may reduce the risk of PTSD. Optimum, analgesia-based sedation may help patients to form factual memories of ICU, so possibly reducing the risk of PTSD. Patient diaries, written by health professionals and family members and close friends, may also support patients in coming to terms with traumatic, delusional memories, and so reduce their emotional and psychological symptoms. Following ICU discharge, validated screening tools such as ICU Memory and Post-traumatic Stress Syndrome 14-Questions Inventory can be used as part of routine follow-up to identify patients who may need referral for more specialist assessment of possible PTSD symptoms.
Using and Understanding Sedation Scoring Systems
Authors: Waldmann Carl
Published: December 2014

In modern intensive care unit practice, the primary goal of sedation is to make patients calm, comfortable, cooperative and communicative. Sedation scoring systems enable staff to assess patients' depths of sedation and so adjust analgesic and sedative therapies to achieve an optimum level of sedation for the individual patient. There is currently no consensus on the choice of instrument, and units should choose and adhere to a sedation scoring system that best fits the needs of their local practice. Regardless of the scale chosen, sedation scoring is best implemented as part of a sedation protocol designed to achieve optimum sedation and support patient-centred care.
National Survey of Fenestrated versus Non-Fenestrated Tracheostomy Tube Use and the Incidence of Surgical Emphysema in UK Adult Intensive Care Units
Authors: Powell Harry R F , Hanna-Jumma Sameer , Philpott Jonathan M , Higgins David
Published: December 2014

Surgical emphysema is a recognised complication of percutaneous tracheostomy (PT) and it has been shown that this is a particular problem when a fenestrated tracheostomy tube is initially used in patients receiving positive pressure ventilation. The recently published ‘Standards for the care of adult patients with a temporary tracheostomy’ produced by the Intensive Care Society UK (ICS) addresses this issue and states that ‘generally fenestrated tracheostomy tubes should not be used while a patient still requires mechanical ventilation because of significant risk of surgical emphysema’. We have conducted a survey of current UK practice to assess whether the guidelines are being followed. This primarily focused on choice of tracheostomy tube, the incidence of surgical emphysema and whether endoscopic confirmation of fenestration placement was performed. The results show that of the units that replied, eight (12%) still routinely insert fenestrated tracheostomy tubes, and all of these reported surgical emphysema as a complication. Only 16% check the position of the fenestrations within the tracheal lumen. In accordance with the ICS guidelines, it is important to use a non-fenestrated tracheostomy tube on initial insertion of PT, especially for patients that require positive pressure ventilation. Where a fenestrated tube is used, operational policies should be reviewed for checking the position and patency of the fenestrations.
Mobilising Oedema in the Oedematous Critically Ill Patient with ARDS: Do We Seek Natriuresis Not Diuresis?
Authors: Morris Craig , Plumb James
Published: December 2014

In the treatment of the acute respiratory distress syndrome in the intensive care unit, one of the aims is to achieve a negative fluid balance. Traditional use of sole-agent loop diuretics such as furosemide often results in the loss of free water, dehydration, hypernatraemia and metabolic alkalosis, with therapeutic failure once water is replaced. A more rational approach is to induce natriuresis with loss of sodium in the urine to reduce extracellular and interstitial fluid volume, not total body water. Polypharmacy with a loop diuretic combined with other weak diuretics to prevent tubules modifying glomerular filtrate, promotes natriuresis with large volume urinary losses and minimal electrolyte disturbance, and the excretion of urine with a composition comparable to plasma.
Intensity of Renal Replacement Therapy: Effects on Mortality and Renal Recovery
Authors: Hornsby Jamie
Published: December 2014

This flawed meta-analysis suggests that in critically ill patients with acute kidney injury (AKI) there is no difference in mortality or renal recovery when comparing high intensity continuous renal replacement therapy (CRRT) or intermittent haemodialysis (IHD) (effluent flow rate 35–48 mL/kg/hr or equivalent) vs lower intensity CRRT or IHD (effluent flow rate 20–25 mL/kg/hr or equivalent) strategies.

Level of evidence: 1− (Meta-analysis with a high risk of bias)
Early Neuromuscular Blockade in Severe ARDS
Authors: Horner Daniel , Cairns Chris
Published: December 2014

This underpowered study suggests that there may be a mortality benefit in early neuromuscular blockade in severe ARDS.

Level of evidence: 1− (RCT high risk of bias).
Lemierre's Syndrome Misdiagnosed as Swine Flu
Authors: Rashid Anwar , Green Christopher , Soni Anupa , Manji Hamid
Published: December 2014

Lemierre's syndrome is characterised by a potentially fatal septic thrombophlebitis and metastatic abscesses caused by Fusobacterium necrophorum (F. necrophorum). It probably occurs more commonly than realised, with 10% of cases of pharyngitis in young adults being due to F. necrophorum and an estimated 1 in 400 of these are likely to develop Lemierre's syndrome. Diagnosis by clinical means alone is difficult and requires a high degree of suspicion, pending laboratory/ radiological confirmation. We describe a case of a 26-year-old male who developed a coryzal illness with sore throat, misdiagnosed as H1N1 influenza in the recent surge, who failed to improve with conservative and antiviral treatment. He was subsequently hospitalised and ultimately required admission to the intensive care unit for the management of septic shock and respiratory failure. The diagnosis of Lemierre's syndrome was made after isolation of F. necrophorum in blood cultures and computerised tomography demonstration of diagnostic features, particularly a left internal jugular vein thrombosis. The mainstay of antibiotic management, as supported by the literature, is a beta-lactamase resistant penicillin or clindamycin together with metronidazole. The use of anticoagulation is controversial. This case highlights the increasing incidence of Lemierre's syndrome, partly due to the current trend to rationalise antibiotic use, and draws readers' attention to the current guidelines for management of pharyngitis from the USA and the National Institute for Health and Clinical Excellence, which recommends antibiotics for patients when three or more of the Centor criteria are met.
Thrombotic Thrombocytopenic Purpura
Authors: Thachil Jecko
Published: December 2014

Thrombocytopenia is the most common coagulation problem in intensive care units with an incidence of up to 60% in some studies. It is often associated with multiple organ failure and high mortality. One of the life-threatening causes of thrombocytopenia in intensive care is thrombotic thrombocytopenic purpura (TTP). It is important that an early diagnosis of this condition is made in critically ill patients since early initiation of treatment can translate into a successful outcome. Patients who are diagnosed with TTP outside critical care units may very often require intensive care management due to the high rate of complications associated with this condition. This review summarises recent advances and outlines a practical approach to patients who are suspected to have TTP.
Rehabilitation within Scottish Intensive Care Units: A National Survey
Authors: Appleton Richard TD , MacKinnon Mairianne , Booth Malcolm G , Wells Julie , Quasim Tara
Published: December 2014

The National Institute for Health and Clinical Excellence (NICE) in Clinical Guideline 83: Rehabilitation after critical illness has set challenging recommendations regarding the routine evaluation for, and provision of, rehabilitation within critical care units. There is no published information regarding current practice in the UK. To establish current practice in Scotland we undertook a telephone survey of all 23 Scottish ICU lead clinicians and physiotherapists − 96% of lead clinicians and 100% of lead physiotherapists completed the survey. Routine assessment for physical (median two (IQR 1–3 [range 0–4])) and non-physical sequelae (median zero (IQR 0–2 [range 0–5])) is low. Aproximately half of ICUs (52%) provide an individualised, structured rehabilitation programme, 32% include activities of daily living and all provide low intensity rehabilitation (eg limb stretching and positioning exercises). There are significant differences (all p<0.05) in the number of units routinely providing more intensive rehabilitation (eg mobilising) while patients have an endotracheal tube versus once extubated.
Continuous Positive Airway Pressure in Acute Respiratory Failure: The Importance of the Valve
Authors: Wagstaff Adrian , Glover Clare , Soni Neil
Published: December 2014

Continuous positive airway pressure (CPAP) is known to improve oxygenation and although the exact mechanism is uncertain, the literature suggests that the positive pressure may have a significant role. There may be other mechanisms. In this study, a lung model was used to investigate the mean fractional inspired oxygen at different respiratory rates delivered by CPAP, a venturi mask with 15 L/min flow and a Hudson mask at 6 L/min flow. In each, the fractional inspired oxygen was set at 0.6. An observational study was then undertaken to determine the effect of CPAP at pressures of 0 cm H2O, 5 cm H2O and 10 cm H2O on oxygenation in patients with acute respiratory failure. The model demonstrated that while the CPAP delivered a fractional inspired oxygen of 0.6 at all respiratory rates and at all pressures, the venturi and Hudson masks both become less efficient as the respiratory rate rose. In patients with acute respiratory failure, there is an initial and immediate rise in the partial pressure of oxygen when the patient changes from a venturi mask to a CPAP system at a pressure of 0 cm H2O but there is no further increase in oxygenation at 5 or even 10 cm H2O. The respiratory rate does, however, decrease with time. The initial effects of CPAP on oxygenation are immediate but do not appear to be significantly influenced by pressure, at least within the first two hours.
The Management of Antihypertensive-Associated Angioedema: When Necessary, Conventional Tracheal Intubation can be Successful
Authors: Young Neil , Clark Donna , Cook Brian
Published: December 2014

Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists are known to be associated with angioedema. These drugs are widely prescribed for hypertension and left ventricular dysfunction, in accordance with NICE guidance. There have been several case series published pertaining to angioedema associated with antihypertensives originating from allergy clinics and emergency departments, but very few from critical care. We present a case series describing the presentation and critical care management of this group of patients. We found that 5 of 16 (31%) patients required tracheal intubation, with only one of these having an awake fibreoptic intubation. Fifteen out of 16 (94%) of these patients survived to hospital discharge. Previous authors have suggested that these patients should always be managed with awake fibreoptic intubation. Our data, although with limited numbers, challenge this approach.
Pneumococcal Pyopericardium Masquerading as Acute Coronary Syndrome
Authors: Smith Zoë A , Wimbush Stephen
Published: December 2014

A 54-year-old man was admitted with a one-week history of chest pain, increasing in severity and worsening dyspnoea. An ECG revealed changes consistent with an acute coronary syndrome (ACS) and a chest X-ray showed an enlarged cardiac shadow. Following admission to the coronary care unit for treatment of presumed ACS his condition deteriorated. A diagnosis of sepsis was made. A CT scan revealed a large pericardial and bilateral pleural effusions. Heart sounds were muffled and neck veins distended, suggesting pericardial tamponade. Echocardiography showed a global pericardial effusion ranging from 2–4 cm with haemodynamic compromise. Sub-xiphisternal pericardiocentesis revealed frank pus from the pericardial cavity and a total of 1,000 mL drained over 48 hours. Rapid haemodynamic improvement ensued. Streptococcus pneumoniae was isolated and the patient was successfully treated with intravenous antibiotics with no requirement for pericardial surgery. In the developed world acute purulent pericarditis is a rare entity with a high mortality rate. Only 10–20% of cases are diagnosed ante-mortem. The condition requires prompt recognition and immediate intervention. The diagnostic picture in this case was initially clouded by the suspicion of ischaemic coronary disease as well as the presence of sepsis. The presentation, management and risk factors associated with this unusual condition are discussed.
Continuous Veno-Venous Haemofiltration in the Management of Severe Hyponatraemia Associated with Transurethral Resection of Prostate Syndrome
Authors: Cowley Nick J , Murphy Nick
Published: December 2014

Modern surgical practice and anaesthetic vigilance has reduced the incidence of profound metabolic disturbance associated with absorption of irrigation fluid during endoscopic transurethral resection (TUR) of the prostate. We describe the critical care management of a patient with severe TUR syndrome, who was successfully managed with continuous veno-venous haemofiltration for the treatment of profound electrolyte disturbance, intravascular volume correction, and treatment of irrigation-fluid glycine toxicity. We examine the rationale for rapid and controlled correction of hyponatraemia in TUR syndrome.
Can Dietary Nitrate Supplements Improve Tolerance to Hypoxia?
Authors: Dauncey Steve
Published: December 2014

This article is a review of the rationale and methodology of a translational study conducted at altitude investigating the potential role of nitrate supplements to improve tolerance to hypoxia, and a discussion of the applicability of the findings to intensive care medicine.
Methods of Measuring Lung Water
Authors: Gupta Rishi K , Newbould Rexford D , Matthews Paul M
Published: December 2014

Pulmonary oedema can result from both cardiogenic and non-cardiogenic aetiologies and is a cause of considerable morbidity and mortality. Accurate methods of quantifying pulmonary oedema are needed for both clinical and research purposes. Applications could include early recognition, and thus prevention, of impending decompensation in heart failure patients, guidance of fluid management in patients with established pulmonary oedema, and as a pharmacodynamic outcome measure for early clinical trials of drugs for the treatment of pulmonary oedema. Magnetic resonance imaging, computed tomography, positron emission tomography, electrical impedance, and thermodilution methods have all been used with the aim of measuring lung water. These methods differ in their accuracy, cost, ionising radiation dose, invasiveness, portability, and ability to provide dynamic measures. To date, none have been established as a ‘gold standard’ clinical measurement to improve clinical outcomes or to assist drug development. This review aims to discuss each of these methods in turn, focussing on advantages, limitations, and possible future development and applications.
Clearing the Spine in the Unconscious Trauma Patient: An Update
Authors: Scott Timothy E , Coates Philip J B , Davies Sian R , Gay David A T
Published: December 2014

Clearing the spine of the unconscious traumatised patient is a task that the intensive care clinician faces frequently. Technological advances in cross-sectional imaging are such that the cervical and thoraco-lumbar spine can now be cleared quickly and reliably in a single computerised tomography imaging session, which all trauma patients require, with no extra exposure to radiation. This results in less patient manipulation and should reduce the time to cessation of unnecessary spinal precautions which themselves can lead to patient harm. Such head-to-toe inclusive ‘traumagrams’ are the standard of care received by casualties presenting at western military medical facilities in Afghanistan.
Invasive Mechanical Ventilation in Acute Exacerbation of COPD: Prognostic Indicators to Support Clinical Decision Making
Authors: Wakatsuki Mai , Sadler Paul
Published: December 2014

Although non-invasive ventilation is the mainstay of management for patients with hypercapnic acute exacerbation of COPD, invasive mechanical ventilation (IMV) still has an important role to play. IMV can be used successfully to reduce mortality and still maintain quality of life in a subset of patients. Despite this, the evidence to support which patients will benefit from IMV is limited. This article reviews the literature available to guide clinician decision-making. Age is not a reliable independent predictor of survival for COPD patients receiving IMV, nor are levels of PaO2, PCO2, or use of long-term oxygen therapy. Body composition and nutritional status are independent predictors of survival and the presence of co-morbidities, such as cor pulmonale, cardiovascular disease and diabetes mellitus are negative prognostic indicators. Length of time in hospital prior to ICU admission also is an adverse prognostic factor. Although scoring systems exist, their ability to predict outcome for individual patients has limitations. Work needs to be done to improve end-of-life planning in COPD with the encouragement of discussion about advance directives when patients are reaching advanced stage of the disease.
Regionalisation of Intensive Care and Extra-Corporeal Membrane Oxygenation Services in the UK: Beliefs about the Evidence, Benefits and Harm
Authors: Stewart Neil I , Gunning Kevin , Cuthbertson Brian H
Published: December 2014

Extra-corporeal membrane oxygenation (ECMO) is used as rescue therapy for adults with severe acute respiratory failure. We aimed to determine the views of intensive care clinicians on regionalisation of critical care services and on the development of adult ECMO services in the UK. A survey was undertaken of all members of the UK Intensive Care Society; 2,133 participants were invited to complete the survey and 691 responded (32.7%). Among respondents, 65% believed that adult ECMO services should be expanded, 42.5% agreed that intensive care services in the UK should be regionalised, while 63.8% agreed the UK should develop regional ventilatory care centres including ECMO services. Experience during H1N1 influenza pandemics was the factor respondents most frequently identified as driving ECMO expansion (61.1%). Of respondents, 60.1% believe that an expanded ECMO service should be provided in 5–10 supra-regional centres. Patient safety, resources, guidelines and transportation of sick patients were also seen as important issues. We conclude that there is a reasonable level of support for regionalisation of intensive care services and for expansion in ECMO services for adults with severe acute respiratory failure in the UK. Clinicians support appropriate funding, investment in transport services and the development of national guidelines.
Does Adrenal Gland Volume Predict Mortality in Septic Shock?
Authors: Morgese Ciro , Flutter Laura , Torlinski Tomasz
Published: December 2014

Adrenal gland volume may be an independent predictor of mortality in patients with septic shock

Level of evidence: 2B (CEBM)
A Guide to Costing and Funding Intensive Care Trials in the United Kingdom
Authors: Walsh Tim
Published: December 2014

This paper provides a guide to the different sources of support for research available in the United Kingdom, and clarifies how these relate to different aspects of a research study in intensive care. It lists the different activities and elements that need to be considered when planning a research study to ensure that it is appropriately resourced, documents how funding for the different research costs and activities should be sought, and gives practical advice regarding how to accurately and realistically cost an intensive care trial.
Glucose Control in Critical Care Oncology
Authors: Cooksley Tim , McAvoy Thomas , Haji-Michael Philip
Published: December 2014

The optimal strategy for glucose control in critically ill patients remains controversial and may vary depending on their diagnostic groups. This retrospective study addresses this question in a cohort of critically ill oncology patients. Serial blood glucose levels were measured in a specialist oncology intensive care unit (ICU) in England between January 2009 and May 2010. Intravenous sliding scale insulin was started when blood glucose levels were greater than 8.3 mmol/L, aiming for a target glucose level below 10 mmol/L. There were 565 patients admitted to the ICU, of whom 181 (32%) were medical and 384 (68%) surgical. The mean blood glucose was 7.8 mmol/L. Mortality rates relative to mean glucose levels followed a U-shaped curve. There was a statistically significant increase in mortality among patients who spent longer periods with blood glucose levels less than 6 mmol/L, and those whose glucose was greater than 10 mmol/L (20% vs 7.3%; p <0.001). Fluctuations in blood glucose levels measured by the coefficient of variation against mean glucose levels demonstrated a significant increase in mortality in patients with higher variability (p<0.01). Higher coefficients of variation were also associated with an increased length of ICU stay and increased readmission rates to ICU. In this study, hypoglycaemia, hyperglycaemia and increased variability in glucose levels were each independently associated with worse outcomes in critically ill patients.
Exertional Heat Stroke – The Athlete's Nemesis
Authors: Walter Edward , Venn Richard , Stevenson Tim
Published: December 2014

Heat stroke represents the extreme end of a spectrum of heat-related illnesses. It can occur in endurance athletes. Its incidence is probably under-reported. Patients present confused, drowsy or comatose, with a raised core temperature, but often a falsely reassuring peripheral temperature. Treatment is centred on reducing the core temperature as rapidly as possible and appropriate supportive management. Even with prompt treatment, it is associated with multi-organ dysfunction and death. Patients are often misdiagnosed, or diagnosed late. This is probably exacerbated by a wide differential diagnosis, the need for a core temperature measurement to reach the diagnosis and clinicians being unfamiliar with the disease. The need for immediate recognition, and immediate treatment compounds the problem. Survivors may experience long-term neurological disability and may be at risk of a further episode. Patients should return to sport gradually and only when they feel well. Its epidemiology, pathophysiology and clinical management are reviewed.
Critical Care Transfer Quality 2000–2009: Systematic Review to Inform the ICS Guidelines for Transport of the Critically Ill Adult (3rd ed)
Authors: Barratt Helen
Published: December 2014

This paper describes the findings of a systematic literature review that was undertaken to inform the third edition of the Intensive Care Society's (ICS) Guidelines for the Transport of the Critically Ill Adult, which has recently been published. Thirty-eight articles were identified relating to the process of adult patient transfer. The bulk of the articles related to transfer quality, including review articles and audits assessing both the standard of transfers and compliance with relevant guidelines. The review demonstrates that the quality of transfers remains a concern, but much of the data is from single centre audits and case series, which are thought to provide the weakest level of evidence. The guidelines have been extensively updated to reflect both current practice and emerging evidence, but it is clear that measures are still needed to improve the quality of transfers.
Hypokalaemia: The Dangers of a Sweet Tooth
Authors: Taylor Ben , Chambers David J , Patel Nehal , Morrison Paul J
Published: December 2014

Liquorice is well known to inhibit the renal tubular enzyme 11-β-hydroxysteroid dehydrogenase, causing a syndrome of apparent mineralocorticoid excess. This is a rare condition, usually resulting from chronic ingestion of liquorice-containing products. The case report relates to an 84-year-old woman with chronic hypertension who developed profound weakness following a liquorice ‘binge’ which, to our knowledge, is only the second reported case of profound metabolic disturbance as a result of acute liquorice ingestion. The differential diagnosis of hypokalaemia and the importance of the clinical history are discussed, with a review of medication and analysis of the acid-base status.
Automated External Defibrillators for Cardiac Arrests in Hospitals
Authors: Garry David
Published: December 2014

The use of automated external defibrillators (AEDs) instead of manual defibrillators after in-hospital cardiac arrest on general wards was associated with lower survival rates among patients with an initial rhythm that was nonshockable. Patients with an initial rhythm that was shockable showed no association between outcome and AED use.

Level of evidence: 2B (individual cohort study)
Intensive Care Management of Subarachnoid Haemorrhage
Authors: Highton David , Smith Martin
Published: December 2014

Aneurysmal subarachnoid haemorrhage (SAH) is a devastating disease associated with high mortality and poor outcome in many survivors. Aggressive treatment by a comprehensive multidisciplinary team is associated with improved outcome, but the intensive care management of SAH presents significant challenges. Multimodal neuromonitoring may detect secondary insults before irreversible neuronal damage has occurred, and is increasingly being used to guide treatment. This article reviews current trends in the intensive care management of SAH from aspects of initial resuscitation to recent developments in the prevention and management of complications, including delayed cerebral ischaemia. Evidence from clinical trials and recent consensus guidance is reviewed.
A Survey of the Implementation of the NHS Diabetes Guidelines for Management of Diabetic Ketoacidosis in the Intensive Care Units of the East of England
Authors: Rudd Bryony , Patel Krishna , Levy Nicholas , Dhatariya Ketan
Published: December 2014

For patients with insulin-treated diabetes, diabetic ketoacidosis (DKA) is a serious acute complication that often leads to intensive care admission. To overcome perceived shortcomings in care, the Joint British Diabetes Societies (JBDS) published national guidelines for the management of DKA in adults in March 2010. A telephone survey of the 13 general adult intensive care units in the East of England during November 2011 examined how widely four key steps of the guidelines had been adopted in the region. The survey demonstrated that while most units had guidelines for the management of DKA, the majority had not adopted the JBDS guidelines. We recommend that future national guidelines for DKA are developed with the participation of the intensive care community and are disseminated to all intensivists.
Efficacy and Safety of Regional Citrate Anticoagulation in Critically Ill Patients Undergoing Continuous Renal Replacement Therapy
Authors: Sheehan James , Ezra Martyn
Published: December 2014

A meta-analysis of randomised controlled trials comparing regional citrate anticoagulation (RCA) to control anticoagulation for haemofiltration revealed that citrate anticoagulation is effective at maintaining circuit patency and reducing the risk of bleeding during haemofiltration. The use of regional citrate anticoagulation also prolongs the haemofiltration circuit life, but this result is not significant when compared to the use of heparin. There was however, marked heterogeneity between trials reported.

Level of evidence: 1- (Meta-analysis with a high risk of bias)
Military Application of Tranexamic Acid in Trauma Emergency Resuscitation Study
Authors: Ghazi Saud , Pierson Richard , Torlinski Tomasz
Published: December 2014

In this retrospective observational study, the addition of tranexamic acid (TXA) to blood component based resuscitation following combat injury showed improvement in measures of coagulopathy and survival, a benefit that was most prominent in those patients requiring massive transfusion.

Level of evidence: 2B
Individualising Management of Severe Respiratory Failure and the Specialist Commissioned Severe Respiratory Failure Service for England
Authors: Barrett Nicholas , Camporota Luigi , Langrish Chris , Glover Guy , Beale Richard
Published: December 2014

Despite the improvement in the survival rate in patients with acute respiratory distress syndrome, there is a cohort of patients with severe hypoxaemia and hypercapnia who offer a significant therapeutic challenge and may require some of the more contentious rescue therapies, including prone positioning, high-frequency oscillatory ventilation and extracorporeal support. It is essential to implement a protocolised pathway for diagnosis and individualised treatment for these patients. In 2011, the English National Specialist Commissioning Service established a number of severe respiratory centres for England including the provision of extracorporeal membrane oxygenation. Early referral is essential for the successful use of rescue therapy as the evidence indicates that the time of mechanical ventilation prior to rescue therapy is a key predictor of mortality. Guy's and St Thomas' NHS Foundation Trust has been commissioned as one of the severe respiratory failure services and we describe the process of assessment and management that we have instituted to manage patients with severe respiratory failure.
Acute Respiratory Distress Syndrome Due to Gadolinium Administration
Authors: Gupta Nidhi , Davidson John , Li Alex
Published: December 2014

We present the rare case of a 37-year-old female presenting with acute respiratory distress syndrome (ARDS) following administration of gadolinium (Gd) chelate during a magnetic resonance imaging (MRI) liver scan.
Probable Catastrophic Antiphospholipid Syndrome Mimicking Severe Sepsis after Digital Amputation
Authors: Chambers Robert , Nolan Kathleen
Published: December 2014

Antiphospholipid syndrome (APLS) is an autoimmune disorder characterised by veno-arterial thrombosis, adverse outcomes in pregnancy and raised titres of antiphospholipid antibodies. The catastrophic variant is rare and makes up less than 1% of cases but carries a high mortality. We present a case of probable catastrophic antiphospholipid syndrome (CAPS) presenting shortly after toe amputation under general anaesthesia.
Out-of-Hospital CPAP in the Treatment of Cardiogenic Pulmonary Oedema
Authors: Oliver Charles M , Narayanan Madan
Published: December 2014

This small multicentre randomised study supports the early institution of CPAP in individuals with cardiogenic pulmonary oedema (CPE). Those in whom CPAP was started alongside medical treatment in a pre-hospital setting were less likely to deteriorate in the first 48 hours when compared with medical treatment alone.

Level of evidence: 2B (CEBM 2011)
Mechanical Support for Heart Failure
Authors: Salaunkey Kiran , Parameshwar Jayan , Valchanov Kamen , Vuylsteke Alain
Published: December 2014

Critically ill patients at extremes of physiology may benefit from mechanical support for heart failure and intensive care practitioners should be knowledgeable about these options. In this article we will discuss the mechanical support for critically ill patients in heart failure. Referral to a specialist centre should be considered early for maximal patient benefit.
Procalcitonin: Does It Have a Role in the Diagnosis, Management and Prognosis of Patients with Sepsis?
Authors: Ingram Nigel
Published: December 2014

There is growing interest in the use of procalcitonin as a biomarker of bacterial infection. In particular, focus has been on the use of procalcitonin to facilitate a more timely diagnosis of sepsis and to guide the appropriate duration of antibiotic therapy. However, there is a lack of consensus in the literature concerning the role of measuring procalcitonin levels in clinical practice. This article reviews the evidence surrounding the utility of this biomarker for patients with sepsis in the intensive care environment. It is concluded that raised procalcitonin levels add little as a diagnostic criterion, however evidence supports the incorporation of procalcitonin-based algorithms relating to antibiotic stewardship in this patient population.
A Case of Refractory Hyperkalaemia in an HIV-Positive Patient with Pneumocystis Jirovecii Pneumonia
Authors: Stangoe Douglas , Jenkins Nicholas , Coakes James
Published: December 2014

A 58-year-old gentleman admitted to the intensive care unit (ICU) with Pneumocystis jirovecii pneumonia and advanced HIV developed a potentially lethal hyperkalaemia secondary to his antibiotic treatment. The mechanism and treatment are described.
Introduction of an Echocardiography Service to a General Intensive Care Unit
Authors: Glen John , Bruemmer-Smith Stefanie , Greenway Timothy
Published: December 2014

Studies have suggested that significant undiagnosed pathology exists in the intensive care unit (ICU) population, and that bedside transthoracic echocardiography (TTE) can aid prompt diagnosis with potential outcome benefits. This study assesses the introduction of a bedside echocardiography service on patient care in a tertiary university intensive care unit (ICU). Data were collected from 101 TTEs, of which 58 were full studies and 43 were screening TTEs with a limited dataset. Seventy-five scans (74%) revealed previously undiagnosed pathology, which was considered serious in 30 (30%) cases. The most commonly diagnosed pathologies were: severe ventricular dysfunction (n=19), severe valvular dysfunction (n=9) and severe pulmonary hypertension (n=4). Full studies were more likely than screening studies to reveal previously undiagnosed pathology (47/58 vs 28/43 studies, p=0.035). However, the number of patients whose management was changed as a result of TTE was not significantly different between the two groups. Overall, patient management was altered as a result of the TTE in 51 cases (50%), and 11 patients (11%) were subsequently referred for cardiology consultation. In keeping with previous work, we have found that TTE uncovered a high percentage of unsuspected cardiac abnormalities, which impacted management in half of the patients who were scanned.
Pain in Intensive Care: A Personalised Healthcare Approach
Authors: Bantel Carsten , Laycock Helen , Ward Stephen , Halmshaw Charlotte , Nagy Istvan
Published: December 2014

For patients admitted to intensive care, pain is a common experience with potentially significant consequences. Pain management needs to evolve from the traditional ‘one-size-fits-all’ plan to a more personalised approach. This can be achieved by appreciating the numerous potential causes of pain, using appropriate assessment tools, utilising a range of potential treatment options and addressing the challenges associated with pain management in this heterogeneous population. At this point a truly multimodal, multidisciplinary management plan can be implemented, aimed at improving pain control and ultimately patient outcomes.
Advances in Ventilation — Neurally Adjusted Ventilatory Assist (NAVA)
Authors: Skorko Agnieszka , Hadfield Daniel , Shah Anand , Hopkins Philip
Published: December 2014

This review aims to introduce neurally-adjusted ventilatory assist (NAVA) to readers who do not have experience in using this form of ventilation. We will describe the basic principles and theoretical advantages of NAVA together with our experiences of introducing and using this mode in an intensive care unit.
The Presence of Relatives during Brainstem Death Testing in an Intensive Care Unit
Authors: Reid Megan
Published: December 2014

The issue of allowing relatives to witness brainstem death testing has sparked debate between all members of the multidisciplinary team working in intensive care. A literature search was carried out, highlighting the advantages and disadvantages of relatives observing brainstem death testing. Databases searched were the NHS Knowledge Network, OVID, CINAHL, the Cochrane Library, and Medline. Search items included: brainstem death, brainstem death testing, brain death, intensive care, relatives, families and witnessed cardiopulmonary resuscitation. Articles which were under ten years old were included; however articles which were pertinent to the topic were not excluded if outside this timeframe.
National Survey of Rehabilitation after Critical Illness
Authors: Berry Andrea , Cutler Lee R , Himsworth Angela
Published: December 2014

This paper reports the results of a survey of compliance with the National Institute of Health and Clinical Excellence (NICE) clinical guideline 83 (CG83) Rehabilitation after Critical Illness1 in NHS hospitals in England. A data collection tool, structured around the detailed recommendations, was distributed throughout the 28 critical care networks in England. Usable data were returned from 59 intensive care units. The overall results show that 52% of units are fully compliant with rehabilitation guidelines for patients within the ICU. This decreases to 48% prior to discharge to the ward. Further reduction in compliance is then seen during the ward stay (27%), prior to discharge from hospital (33%) and at 2–3 months following discharge from intensive care (31%). There are health inequalities in this area that are proving challenging to overcome. Further evidence of the best way to deliver rehabilitation and its long-term health and economic benefits is required.
Use of a Shortened Endotracheal Tube as a Tracheostomy Tube in a Morbidly Obese Patient
Authors: Zafiropoulos Andreas J , Hodgson Luke E , Spring Colin
Published: December 2014

The rising prevalence of morbidly obese patients presents unique challenges to the intensivist, including management of the airway. We present a case where commercially available tracheostomy tubes were of insufficient length due to the patient's body habitus, with potentially disastrous consequences. As a solution, an endotracheal tube was used as the tracheostomy tube to provide sufficient length for correct positioning and to enable weaning from mechanical ventilation. The adjustable flange from a tracheostomy kit was used to secure the tube in position. Our case illustrates one possible solution to the problem of tracheostomy tube positioning in morbidly obese patients.
Tranexamic Acid in Traumatic Bleeding — for Everyone?
Authors: Taylor Nicholas , Kirk-Bayley Justin
Published: December 2014

Tranexamic administration to patients with traumatic bleeding is associated with decreased mortality (NNT 48) and thrombotic events (NNT 167), irrespective of injury severity.

Level of evidence: 1B
A Late Presentation of Dynamic ECG Conduction Abnormalities following Blunt Chest Injury
Authors: Lad Tanuj S , Gorman Keiron , Watson David , Kennedy Daniel
Published: December 2014

Cardiac abnormalities following blunt chest trauma can range from minor ST changes to arrhythmias, cardiac rupture, cardiogenic shock and death. A normal electrocardiogram (ECG) on presentation does not guarantee the absence of myocardial injury, and with no gold standard test to detect the condition, myocardial contusion is often identified only at autopsy. We describe the late presentation of evolving and dynamic conduction abnormalities on the ECG, including a sinusoidal conduction pattern, in a young trauma patient. This sequence of conduction abnormalities has not previously been observed and we discuss the potential explanations.
Hypertriglyceridaemia-Induced Acute Pancreatitis: Is Plasmapheresis Really Indicated? 3C00
Authors: Collis Lauren G , Chambers David J , Carr Bryan
Published: December 2014

A 47-year-old man presented with severe acute pancreatitis, thought to be hypertriglyceridaemia-induced. Serum triglyceride concentration fell from 42.4 mmol/L to 5.9 mmol/L by day three with fasting alone. Hypertriglyceridaemia precipitates a small but significant proportion of acute pancreatitis episodes, especially during pregnancy. Treatment strategies are discussed, with special focus on plasmapheresis. The reduction in serum triglyceride concentration achieved by plasmapheresis is similar to that achieved by fasting alone, or in conjunction with insulin or heparin therapy. It is possible that plasmapheresis may offer the patient more harm than benefit. Currently, there is insufficient evidence to either recommend or reject plasmapheresis in triglyceride-induced acute pancreatitis.