bluuebunny/crossref_metadata_2025 huggingface dataset:
Unsuccessful trial accrual and human subjects protections: An empirical analysis of recently closed trials
Authors: Carlisle Benjamin , Kimmelman Jonathan , Ramsay Tim , MacKinnon Nathalie
Published: December 2014

Background

Ethical evaluation of risk–benefit in clinical trials is premised on the achievability of resolving research questions motivating an investigation.

Objective

To determine the fraction and number of patients enrolled in trials that were at risk of not meaningfully addressing their primary research objective due to unsuccessful patient accrual.

Methods

We used the National Library of Medicine clinical trial registry to capture all initiated phases 2 and 3 intervention clinical trials that were registered as closed in 2011. We then determined the number that had been terminated due to unsuccessful accrual and the number that had closed after less than 85% of the target number of human subjects had been enrolled. Five factors were tested for association with unsuccessful accrual.

Results

Of 2579 eligible trials, 481 (19%) either terminated for failed accrual or completed with less than 85% expected enrolment, seriously compromising their statistical power. Factors associated with unsuccessful accrual included greater number of eligibility criteria (p = 0.013), non-industry funding (25% vs 16%, p < 0.0001), earlier trial phase (23% vs 16%, p < 0.0001), fewer number of research sites at trial completion (p < 0.0001) and at registration (p < 0.0001), and an active (non-placebo) comparator (23% vs 16%, p < 0.001).

Conclusion

A total of 48,027 patients had enrolled in trials closed in 2011 who were unable to answer the primary research question meaningfully. Ethics bodies, investigators, and data monitoring committees should carefully scrutinize trial design, recruitment plans, and feasibility of achieving accrual targets when designing and reviewing trials, monitor accrual once initiated, and take corrective action when accrual is lagging.
Just Criminology: The Legacy of Jock Young
Authors: Carlen Pat
Published: December 2014

In his search for a just criminology, Jock Young displayed a courageous originality in his uses of critique and imagination. It is argued that one of Young’s unique legacies to criminology might be that, in fashioning the new, he tried out every conceivable method – including irony, satire and contradiction – for understanding and transforming the old. This is why he was constantly changing perspective, sometimes privileging one mode of analysis, sometimes another. But Young’s contradictory or challenging analyses never led to a closing-off of debate, either with others or, more importantly, with himself. So – and ironically – although each of his books is an invitation to think, rather than to follow, there is much to be learned from a critical appreciation of the courage with which Jock Young practised a fully sociological criminology.
More than just a famous face: Exploring the rise of the celebrity expert-advocate through anti-trafficking action by the Demi and Ashton Foundation
Authors: Steele Sarah L. , Shores Tyler
Published: December 2014

While the criminological literatures explore celebrity trials and investigations, the celebrity’s placement as an actor in criminal justice processes – and as an authoritative voice on crime – remains less investigated. With celebrity activism and testimony increasing around issues like human and child trafficking, this article contemplates the celebrity as an ‘expert-advocate’ who reinforces the state’s ability to regulate, especially in light of ongoing challenges to its sovereignty, such as trafficking. Through the Demi and Ashton (DNA) Foundation’s ‘Real Men’ and Customs and Border Protection campaigns, we note that celebrities are no longer just ‘public faces’, but also members of a ‘firm’ working with the state to recreate the illusion of state sovereignty, bolstering borders and divides. We call for further research into celebrities as influential agents in the criminal justice system.
UK Ironsplent's Potential Donor Audit
Authors: Conner Stephen
Published: December 2014

The wide variation in cadaveric organ donor rates across Europe is well recognised.
The 23rd International Symposium on Intensive Core and Emergency Medicine
Authors: Kapila Atul
Published: December 2014

Not being able to get away on the Monday meant it was the Tuesday 06:50 British Midland flight out of Heathrow and only 2 hours late getting into Brussels city centre.
Report from the ESICM ESICM March 2003 Brussels
Authors: Hinds Charles , Soni Neil
Published: December 2014

This years Council meeting was held in the ESICM Offices out near the Airport which is an interesting drive from Gare Midi across the part of Brussels not advertised in the travel brochures. It is curious to note that the high speed link between Waterloo and the Brussels Office is still incomplete between London and the Tunnel but also between Central Brussels and the Offices. Hence the cab. However the weather was great with the sun shining over the rather modern Industrial Estate and with the cerulean blue skies reflected in the windows of the Erasme Hospital.
Education and Training Needs Assessment
Authors: Batchelor Anno
Published: December 2014

Many of you will remember being accosted by me either at the State of the Art meeting or by email asking what your (or your trainees) educational needs are and what the Society should be doing to help you fulfil them.
Intensive Care Society Swindon Workshop Report
Authors: Watters Malcolm
Published: December 2014

Holding an ICS workshop on a hot summer's day during school holidays is on the face of it, not the brightest idea, unless the content of the day is very appealing. Fortunately the quality of presentations at this workshop ensured that those who gave up a days work, sunbathing or watching the Open golf on television were well rewarded.
Can Altitude Research Benefit Critically ill Patients?
Authors: Grocott Mike
Published: December 2014

The Caudwell Xtreme Everest (CXE) expedition in the spring of 2007 was a large field-study investigating adaptive responses to hypoxia, and was supported by a grant from the Intensive Care Foundation. This article sets out to explain why the CXE team went to Everest, what they hope to learn, and discusses some of the key studies.
Practical Approaches to HIV Testing in the Intensive Care Unit
Authors: Taegtmeyer Miriam , Beeching Nick
Published: December 2014

Diagnostic and ethical dilemmas around HIV testing are a common problem for the intensivist, whose patients may be unconscious. Emphasis on increased testing by the non-specialist sharpens the focus of this debate in the UK and raises specific questions around how this can be achieved within the current legal and ethical framework. In this article we outline the natural history of HIV for the non-specialist and discuss the legal and ethical interface with intensive care medicine through the use of specific clinical case studies. We argue that ICU clinicians should have a very low threshold for offering HIV tests whenever clinical or epidemiological indicators are present. There is nothing ‘special’ about HIV testing except that specific consent still has to be obtained, in confidence, from conscious patients. Testing is indicated whenever it is in the clinical interests of the patient. The small proportion of situations that are less straightforward can be discussed with and/or be dealt with by the local HIV team.
Hydrocortisone Therapy for Patients with Septic Shock
Authors: Sim Kevin , Cairns Chris
Published: December 2014

In patients with septic shock, the administration of corticosteroids leads to faster resolution of shock but has no effect on mortality at 28 days or at one year.

Level of evidence: 1+ (RCT with a low risk of bias)
The Accuracy of Diagnostic and Haemodynamic Data Obtained by Transthoracic Echocardiography in Critically Ill Adults: A Systematic Review
Authors: Colebourn Claire , Barber Vikki , Salmon Jon B , Young Duncan
Published: December 2014

We systematically assessed the utility of diagnostic data and the accuracy of haemodynamic data obtained by transthoracic echocardiography in critically ill adults, by examination of prospective studies in unselected adult intensive care patients. Of the ten studies identified, three examined the diagnostic utility of transthoracic echocardiography. Thirty-eight percent of clinical questions were answered by a single transthoracic echocardiogram. The weighted mean percentage of clinical findings yielded by transoesophageal echocardiography not found by the transthoracic approach was 33% (range 28–50%).

Four studies examined the correlation between transthoracic echocardiographic estimation of pulmonary artery occlusion pressure and pulmonary artery catheter-derived measurement. Correlation was strong in all studies: for example in one study r=0.98, p<0.001, with a mean difference of 0.0 (2.5) mm Hg by the Bland-Altman technique.

Three studies examined the correlation between transthoracic echocardiography and thermodilution-derived cardiac output measurement. Correlation varied with the echocardiographic technique used and correlated best with Dopplerderived measurement: r=0.93, p<0.0001, mean difference of 0.2 (0.82) litres per minute.

The diagnostic utility of transthoracic echocardiography compared with transoesophageal echocardiography in the critically ill cannot be reliably assessed from the available studies. More relevantly designed studies are required. Transthoracic echocardiography can accurately estimate pulmonary artery occlusion pressure, but the technique requires the patient to be in sinus rhythm. Transthoracic echocardiography can also accurately estimate cardiac output in the critically ill. Further studies should concentrate on Doppler-based assessments. The scene is now set for the development of this valuable non-invasive tool.
The Outcome of Haematological Malignancy in Scottish Intensive Care Units
Authors: Cuthbertson Brian H , Rajalingam Yadhu , Harrison Simon , McKirdy Fiona
Published: December 2014

To study the prognostic indicators and outcome in patients with haematological malignancy requiring intensive care, we identified 714 adult patients and analysed their clinical audit data. Mean APACHE II score was 24. Main admitting diagnoses were acute lymphoma (43%) and acute leukaemia (28%). There was a high requirement for acute organ support. Intensive care unit (ICU) mortality was 39% and hospital mortality 55%, with a standardised mortality rate of 1.05 (0.98–1.13). Factors predictive of outcome after multivariate analysis were: cardiopulmonary resuscitation (CPR) in the 24-hours before ICU admission, inotropic support in the first 24-hours, APACHE II score and requirement for ventilatory support immediately prior to, or at admission to the ICU. Neutropaenia was not an independent predictor. Patients with neutropaenic septic shock and multiorgan failure left hospital. Hospital mortality for this group is comparable to that of non-cancer patients admitted with multi-organ system failure. The reluctance to admit such patients to ICU may be unjustified.
Dosing Regimes for Antimicrobials during Continuous Veno-Venous Haemofiltration (CVVH)
Authors: Glossop Alastair J , Seidel Jochen
Published: December 2014

The pharmacokinetic profile of antibiotics used in critically ill patients during continuous haemofiltration is different both from healthy people and from stable patients on long-term dialysis. This article reviews the patient-related, drug-related and haemofiltration-related variables influencing drug elimination in this group of patients, and provides specific recommendations for antibiotic dosing for different classes of antibiotics. Loading doses do not need to be altered. Subsequent dose adjustment should be based on the estimated ultrafiltration capacity of the renal replacement technique and the degree of extracorporeal clearance. A table of recommended doses is provided.
Patient Confidentiality and the Intensivist
Authors: Kotak Dee , Lawson Andrew
Published: December 2014

Confidentiality is a patient's right and is central to trust between doctors and patients. Any disclosure and use of confidential patient information needs to be both lawful and ethical. The duty of confidentiality arises out of the common law of confidentiality, the Human Rights Act, General Medical Council guidelines, NHS staff employment contracts and ethical mores. Breaches of confidence, inappropriate use of health records or abuse of computer systems may lead to disciplinary measures, bringing into question professional registration and possibly resulting in legal proceedings.

Whilst law and ethics in this area are largely in step, the law provides a minimum standard that does not always reflect the appropriate ethical standards that the government and the professional regulatory bodies require. The duty to preserve confidentiality can present intensivists with ethical and/or legal dilemmas. This article summarises the general principles of confidentiality and reviews the legal and professional requirements that intensivists need to be cognisant of when dealing with third party requests for patient information.
A Protocol Mandating a Daily Interruption of Sedatives and Spontaneous Breathing Trial Improves Patient Outcome
Authors: Irvine Michael , Cairns Chris
Published: December 2014

In critically ill, mechanically ventilated, non-surgical patients, a protocol pairing daily mandatory sedation breaks (spontaneous awakening trials – SAT) with spontaneous breathing trials (SBT) results in earlier extubation, shorter ICU stay, shorter hospital stay and lower mortality at one year (NNT=7) compared to standard care.

Level of evidence: 1++ (RCT with a low risk of bias)
Low Dose Epoetin Alfa in Critically Ill Patients
Authors: Tanner Oona , Cairns Chris
Published: December 2014

Use of low dose epoetin alfa in the critically ill does not reduce the number of patients requiring blood transfusion, or units of red blood cells transfused. There may be a mortality benefit in trauma patients. Epoetin alfa is associated with an increased risk of thrombotic events.

Level of evidence: 1++ (RCT with a very low risk of bias)
Trends in Outcomes from Adult General Critical Care Units: Potential Outcome-Based Quality Indicators other than Case-Mix Adjusted Mortality
Authors: Welch Catherine A , Harrison David A , Rowan Kathryn M
Published: December 2014

Over the past 25 years, various outcome-based quality indicators other than mortality have been proposed as performance or quality indicators for monitoring outcomes from adult, general critical care units in the UK. A descriptive trend analysis of the several potential outcome-based quality indicators from Case Mix Programme data for the five-year period 2003 to 2007 is reported. Delayed discharge has shown a large increase over time while out-of-hours discharges have shown a modest increase over time. Premature discharge, inter-hospital critical care unit-to-unit transfers, both overall and for a non-clinical reason, early readmissions and post-unit mortality have all decreased slightly. Early analysis indicates that almost 5,000 bed-days were ‘lost’ for approximately 20,000 admissions due to delayed discharge. The percentage of discharges that occur out-of-hours has continued to increase steadily over the past five years and now stands at around 10%. It is hoped that these data might contribute to discussions on agreeing the most appropriate outcome-based quality indicators to use in adult, general critical care.
Planning a Level Two Unit for Medical Patients: A Prospective Study
Authors: Garry David , Garry Sylvia , Kacelnik Oliver , Vincent Laura , Watkinson Peter
Published: December 2014

Critical care provision in the UK is evolving, driven by increased patient expectations, increased resource, restructuring of trusts and changes to the way health care is funded. Part of this recent change is reflected in an increase in demand for level 2 beds. The John Radcliffe Hospital in Oxfordshire is a teaching hospital with over 700 inpatient beds and several on-site specialised critical care units, but no dedicated level 2 unit. Level 2 care for general medical patients is provided in the 16-bed adult intensive care unit (ICU). We performed a prospective study to allow for planning of a level 2 medical unit, by collecting data on candidates for level 2 care over a 57-day period. We identified 157 medical patients who required a total of 222 bed-days. We calculated that a six-bedded unit would run at full capacity for 88% of the time. This study could be performed in any hospital that needs level 2 care facilities, and could be modified to include surgical patients.
Special Section – Sedation in Intensive Care Seminar
Authors: Gunning Kevin
Published: December 2014

Sedation is one of the commonest therapies that we use in intensive care. An international survey of 3,500 patients in 2005 showed that 68% of patients who were ventilated for more than 12 hours received sedation at some time during their stay in intensive care. Although we prescribe sedation on a daily basis, we do not always do so well, or give it the attention it deserves. It is only over the last ten years that we have begun to be aware of the importance of sedation and its impact on the way we care for our patients. We are more aware of the potential harm resulting from the way in which we sedate patients and the drugs that we use. Hopefully we have moved away from the scenario Thomas Petty described in 1998, “I am troubled today when I make rounds in critical care…., but what I see these days are paralysed, sedated patients lying without motion appearing to be dead.” Patients today are more likely to be awake and comfortable on a ventilator. We have begun to investigate the consequences of over sedation, such as delirium and post traumatic stress disorder. There is still a long way to go however, before we can say that we have implemented the current evidence base into our daily clinical practice.

The three articles on sedation in this edition of JICS are based on talks given at a one day ICS Symposium in July of this year which was sponsored by GSK who have also supported the publication of these articles. The feedback from the seminar was very positive and shows there is a real interest in the subject. We hope to repeat the seminar next year to coincide with the publication of the ICS guidelines on sedation and analgesia.
A Rare Case of Refractory Shock: The Underlying Cause Masked by Fake Tan
Authors: Wilkinson Kirstin , Newman Barry
Published: December 2014

Cases of refractory shock in young people are not common and they may have unusual underlying precipitants. Addison's disease is a rare endocrine condition and even rarer when it exists in combination with another autoimmune endocrine deficiency. We report a case of adrenal crisis in a young patient not known to suffer from Addison's disease. Despite prolonged resuscitation with consideration of uncommon precipitants, this patient died. We review the literature on Addison's disease and adrenal crises and discuss the relevant clinical features of this case.
Low dose Vasopressin in Septic Shock
Authors: Docking Robert , Rooney Kevin , Cairns Chris
Published: December 2014

The addition of low-dose vasopressin to the treatment of septic shock does not reduce mortality compared to the use of norepinephrine alone, but allows a rapid reduction in norepinephrine requirements.

Level of evidence: 1+ (RCT with a very low risk of bias)
Prone Positioning has no Effect on Mortality in ARDS
Authors: Puxty Alex , Cairns Chris , Daniel Malcolm
Published: December 2014

In patients with acute respiratory distress syndrome (ARDS), prone positioning improves oxygenation but has no impact on mortality, except perhaps in those with Simplified Acute Physiology Score (SAPS) II >50.

Level of evidence: 1+ (SR based on small RCTs, conducted prior to ARDSNet – subsequent change in practice)
Setting PEEP in ALI/ARDS
Authors: Griffiths Sue , Cairns Chris
Published: December 2014

Compared to a low tidal volume/low PEEP strategy, a low tidal volume/fixed plateau pressure/higher PEEP strategy offers no mortality benefit but may be associated with reduced morbidity.

Level of evidence: 1+ (RCT with a low risk of bias)
The European Diploma in Intensive Care –EDIC
Authors: Benington Steve , McGrath Brendan
Published: December 2014

The European Diploma in Intensive Care (EDIC) is a two part examination set by the European Society of Intensive Care Medicine. It is becoming increasingly popular with UK trainees who see possession of a diploma as an advantage when applying for consultant posts. Part 1 is a multiple choice paper testing factual knowledge, while Part 2 tests clinical skills and judgement at the bedside and through oral examination. Candidates sitting the Part 2 examination will have completed at least 24 months' ICM training (including complimentary specialties), and must convince the examiners that they would be capable of managing patients on a general intensive care unit to the standard expected of a consultant.
Active Gas Scavenging is Unnecessary When Using the AnaConDa Volatile Agent Delivery System
Authors: Marbini Hosnieh Djafari , Palayiwa Eileen , Chantler Jonathan
Published: December 2014

The AnaConDa filter system has been used in intensive care units (ICUs) to deliver low concentrations of volatile anaesthetic agents to treat severe airflow obstruction and for sedation. The manufacturer and a recently published review recommend the use of a scavenging system with the device. It is unclear from the literature what levels of volatile agent staff are exposed to when the device is being used in ICU without a scavenger. We carried out an observational study requested by the local occupational health department to measure the levels of ICU staff exposure to isoflurane when the AnaConDa delivery system was used to treat asthma. This study was carried out using an ambient air analyser while the patient was receiving therapeutic levels of isoflurane via the AnaConDa device. We conclude that gas scavenging may not be necessary when using the AnaConDa device to deliver therapeutic doses of isoflurane.
Tight Glucose Control in ICU Patients does not Reduce Hospital Mortality
Authors: McGregor Calum A
Published: December 2014

In ICU patients, tight glucose control is not associated with significantly reduced hospital mortality, but is associated with a decreased risk of septicaemia and an increased risk of hypoglycaemia.

Level of evidence: 1++ (Meta-analysis with a very low risk of bias)
Silver-Coated Endotracheal Tubes and the Incidence of Ventilator-Associated Pneumonia
Authors: Bongale Santosh , Cairns Chris
Published: December 2014

The use of silver coated endotracheal (ET) tubes leads to statistically significant reduction in ventilator associated pneumonia (VAP) during the first 10 days of intubation. However methodological flaws lead to doubts over the clinical validity of this result.

Level of evidence: 1− (RCT with a high risk of bias)
Veterinary Critical Care
Authors: Humm Karen , Goggs Robert , Adamantos Sophie
Published: December 2014

Emergency and critical care is a small but rapidly expanding discipline in veterinary medicine. This article outlines the history and current practice of veterinary emergency and critical care medicine within the UK
A Comparison of Mixed and Central Venous Oxygen Saturation in Patients during and after Cardiac Surgery
Authors: Sekkat Hicham , Sohawon Schoeb , Noordally S Oaleed
Published: December 2014

Monitoring of mixed venous oxygen saturation (Sv̄O2) allows assessment of the global balance between oxygen supply and demand. Sv̄O2 measurement requires the insertion of a pulmonary artery catheter (PAC) whereas central venous oxygen saturation (ScvO2) monitoring only requires a central venous catheter. The aim of this study was to assess how continuous measurements of ScvO2 relate to simultaneous measurements of Sv̄O2 during and after cardiac surgery. Continuous Sv̄O2 and ScvO2 measurements in 15 patients undergoing elective cardiac surgery were recorded each minute for 24 hours. Bland-Altman analysis of 9,382 paired data points for Sv̄O2 and ScvO2 revealed a mean bias of 4.4% (95% Cl +22.3, −13.6%). Considerable inter- and intra-individual variability was noted. Based on these data and previous studies, ScvO2 and Sv̄O2 are not interchangeable variables.
Catheter-Related Bloodstream Infection in the Intensive Care Unit
Authors: Curtis Roxana
Published: December 2014

Catheter-related bloodstream infection (CRBSI) is a significant cause of morbidity and mortality in the intensive care unit, contributing to prolonged stay with the associated cost and resource implications. Various mechanisms of infection have been suggested, and consequently, numerous interventions to reduce the burden of infection have been proposed, the efficacy of most of which remains controversial. The practice of routine catheter change and preferential use of the subclavian vein insertion site are both associated with an increased risk of mechanical complications, which may outweigh any potential benefit. Additionally, the use of silver- and antiseptic-impregnated catheters, of questionable benefit in the ICU patient population, is also argued to be unjustified in terms of efficacy and cost.

A small scale study in a London university district general hospital ICU found that while infection rates were low, the majority of infections were caused by Staphylococcus epidermidis and thus were probably a result of contamination either from the patient's commensal flora or acquired by contamination from healthcare workers. In accordance with published findings, this suggests that preventing contamination will decrease infection rates. Strict aseptic technique and the use of sterile fields during insertion are most likely the main contributors in reducing rates of infection. This together with education of staff across disciplines and adherence to local guidelines are likely to be the mainstays of reducing CRBSI in the ICU.
Case Report: An Unusual Presentation of Ethylene Glycol Poisoning
Authors: Glossop Alastair J , Bryden Daniele C
Published: December 2014

A 42-year-old man presented to the intensive care unit with respiratory and renal failure, nine days after admission to hospital with acute renal failure and a raised anion-gap acidosis. He went on to develop an acute, painful ascending motor and sensory neuropathy. Ethylene glycol toxicity was diagnosed on the basis of nerve conduction tests, a renal biopsy showing oxalate crystals, and retrospective analysis of admission blood tests. The case reviews diagnosis and treatment of ethylene glycol toxicity. It also raises the ethical dilemmas faced by staff treating patients who deny ingestion in the face of the evidence.
‘Open-lung’ Ventilation Strategies and Acute Lung Injury (ALI)/Acute Respiratory Distress Syndrome (ARDS)
Authors: Brett Michael J
Published: December 2014

An ‘open-lung’ ventilation strategy that includes low tidal volumes, recruitment manoeuvres and high levels of PEEP does not reduce hospital mortality in patients with acute lung injury or acute respiratory distress syndrome

Level of evidence: 1+ (RCT with a low risk of bias)
A Review of the Accuracy of Death Certification on the Intensive Care Unit and the Proposed Reforms to the Coroner's System
Authors: Tuffin Robert , Quinn Andrew , Ali Faisal , Cramp Paul
Published: December 2014

The requirement for the certification of death in the United Kingdom (UK) is currently undergoing unprecedented change, partly because of the Shipman Inquiry. Doctors undergo little training in completion of death certificates and inaccuracies can therefore arise. This survey compares the causes of death of 30 patients as cited by trainees, consultant intensivists and a consultant pathologist in one intensive care unit. We also review the changes in death certification that may be instituted as a result of proposed reforms to current legislation.
Clinical Leads for Organ Donation: Making it Happen in Hospitals
Authors: Murphy Paul G , Logan Lesley
Published: December 2014

The report from the Organ Donation Taskforce into the relatively poor rates of donation in the UK called for a complete overhaul of the processes that currently support the identification, referral and management of potential organ donors dying in our hospitals. Although some of the specific recommendations of the Taskforce refer to the responsibilities of national bodies such as the Department of Health or NHS Blood and Transplant, at the very heart of the Taskforce report are those recommendations that are concerned with how the option of donation is made available to patients when they die. Thus, the Taskforce recommended that donation should be a component of end-of-life care, that brainstem death should be diagnosed wherever possible and that potential donors should always be referred according to defined minimum criteria and regardless of apparent donation potential. However, it was recognised that this was unlikely to happen unless every hospital had a team to make it possible - the Donation Committee - that was chaired and driven by a non-clinical champion, enhanced by a donor transplant co-ordinator and lead by a clinician. This paper develops these themes and describes, by focusing on a collaborative relationship between donor transplant co-ordinators and clinical leads for organ donation, how real improvements in the number of organ donors might be achieved.
Towards Standardisation of Drug Infusion Concentrations in UK Critical Care Units
Authors: Borthwick Mark , Keeling Susan , Keeling Peter , Scales Katie , Waldmann Carl
Published: December 2014

There is wide variation in infusion practice in UK critical care units. Standardising infusion concentrations may lead to efficiency gains through reduced training burdens, common nomenclature, reductions in error rates and mass production of ready-to-use products by the pharmaceutical industry. A proposed list of standard concentrations for 20 medications given by infusion was produced. Critical care units were surveyed to assess the acceptability of the list for adoption as a national standard; 164 critical care units responded (63% of UK NHS trusts). High acceptance of the list has been shown, with the exception of concentrations of adrenaline, potassium and phosphate where further work is required. The proposed concentrations of the remaining 17 medications should be adopted as a national standard.
Are Front Line Health Professionals Responsible for the Organ Crisis?
Authors: Walters Thomas P
Published: December 2014

The process and techniques of organ transplantation have improved significantly; however, there remains a supply-demand mismatch that appears to grow wider as years go by. In this literature review, databases covering published studies from 1990 to 2006 were searched for studies focused on medical doctors' and/or registered nurses' attitudes towards human-to-human organ donation and/or transplantation. The results indicate that healthcare professionals do play a significant part in the procurement of organs for transplantation and may be partly responsible for the lack of transplantable organs available. However, the review further illustrates their complex role within the healthcare system, and suggests that responsibility for organ procurement may be best placed within the domain of specialist personnel.
Transfusion-Related Acute Lung Injury — A Review
Authors: Thachil Jecko , Erinjeri Joseph F , Mahambrey Tushar D
Published: December 2014

Transfusion-related acute lung injury (TRALI), a type of non-cardiogenic pulmonary oedema related to blood transfusion, is gaining prominence as a common adverse event related to blood transfusions in hospitals. Various mechanisms have been postulated to cause TRALI including both antibody-related and non-immune mechanisms. Although transfusion of all types of blood components have been implicated, by far the commonest product related to TRALI was, until recently, fresh frozen plasma, especially that obtained from female donors. However the use of male-only plasma donation in the UK has resulted in an increased observance of TRALI with platelet and red cell transfusions. The diagnosis of this condition is primarily one of exclusion of other causes of pulmonary oedema, with specialist laboratory tests performed to support the diagnosis. The management of TRALI is early diagnosis and good supportive care with, occasionally, ventilatory support. An increased awareness of this complication among intensive care physicians is desirable to prevent one of the commonest and most frequently under-recognised transfusion-related adverse events of the present day.
A Protocol for Evidence-Based Feeding Guidelines in Critically Ill Adults Does Not Improve Mortality
Authors: Pugh Edward
Published: December 2014

In critically ill adult patients expected to have an ICU stay greater than 48 hours, the use of an evidence-based protocol for feeding results in improved nutrition but no significant reduction in mortality compared to standard care.

Level of evidence: 1+ (RCT with a low risk of bias)
Lateral Medullary Syndrome Causing Vocal Cord Palsy and Stridor
Authors: Nicholson James , Paralkar Ulka , Lawton Greg , Sigston Paul
Published: December 2014

We report a 63-year-old patient with lateral medullary syndrome secondary to a medullary haemorrhage, causing unilateral vocal cord palsy which precipitated respiratory failure sufficient to warrant intubation and ventilation. The patient recovered completely following neurological rehabilitation and was discharged home a month later. Centrally-mediated vocal cord palsy is a rare cause of stridor, but should be suspected in cases where no other local cause can be found.
Haemodiafiltration for Poisoning with an Unknown Substance
Authors: Cottle Daniel , Dean Paul , Mousdale Stephen
Published: December 2014

We describe the case of a young male, found collapsed following poisoning with an unknown substance. He had a Glasgow Coma Score (GCS) of three with a profound metabolic acidosis, despite poisoning with a substance which was strongly basic. He was treated with haemodiafiltration to correct the biochemical derangements. The poison was found to be cyanide, so the patient was also given sodium thiosulphate as an antidote. We review the pathophysiology of cyanide toxicity, the antidotes available and discuss the role of haemodiafiltration in poisoning where the ingested substance is unknown.
The Science of Improvement as it Relates to Quality and Safety in the ICU
Authors: Peden Carol J , Rooney Kevin D
Published: December 2014

This paper seeks to explain some of the science and concepts used in quality improvement, including the use of run charts and control charts, the development and use of ‘bundles’ and the need to reduce variability to improve quality in critical care.
Survey of Family-Witnessed Brain Stem Death Testing in Intensive Care Units
Authors: Dean Pamela A , Booth Malcolm G
Published: December 2014

It is not currently known how often relatives are present during brain stem death (BSD) testing. A telephone survey of a selection of UK intensive care units (ICUs) was therefore performed asking about their experience with family-witnessed BSD testing. Forty-eight ICUs participated. Relatives were allowed to witness BSD testing in 21 ICUs (44%). Despite initial concerns by some ICU staff, none had experienced any problems with the family being present during the testing procedure.
Severe Invasive Pneumococcal Sepsis Associated with Influenza a Infection
Authors: Gulliford Stephen Richard , Checkley Eleanor
Published: December 2014

We present two patients admitted to the intensive care unit with sepsis secondary to severe community-acquired pneumococcal pneumonia who had, in addition, influenza A positive serology. Both Streptococcus pneumoniae and influenza A are known to be responsible for significant morbidity and mortality in their own right during the winter months. This report highlights the need, in cases of confirmed pneumococcal pneumonia, to test for other organisms at an early stage, in particular influenza A and other respiratory viruses, as this synergistic combination is known to carry a very high mortality. The early detection of the influenza A virus in addition to pneumococcus and early treatment with oseltamivir could potentially improve clinical outcomes in this condition.
Ketamine as an Alternative to Etomidate in the Pre-Hospital Setting
Authors: Hawthorne Chris , Cairns Chris
Published: December 2014

Ketamine is a safe alternative to etomidate for emergency intubation and is associated with significantly less adrenal insufficiency.

Level of evidence: 1+ (RCT with a low risk of bias)
Checking Pupils from the Head-End of a Patient during an Ambulance Transfer
Authors: Zafar Naveed , Mohammad Ausim , Jlala Hatem , Winter Bob
Published: December 2014

This pilot study was undertaken to determine whether it was possible to check patients' pupils while sitting restrained at the head-end of an ambulance trolley during a transfer. Using a standard pen torch, twenty-six participants were invited to check the pupils of a manikin strapped to a trolley, by sitting at the head-end of the trolley, without removing their seat belt. Participants and two trained observers were asked separately to assess the difficulty of seeing the pupils, using a three-point scale, the view graded as: impossible, seen with difficulty, easy. Thirteen participants found the task impossible to perform, compared to six who found it easy. Height and gender had minimal influence on the ability to check pupils. Half of the participants could not perform the task. A review of current transfer guidelines and a change of the design of the ambulance or the restraint system to promote staff and patient safety are suggested.
Bridging the Gap: Training Critical Care Clinician-Echocardiographers through a Collaborative Curriculum
Authors: Colebourn Claire L , Davies Imogen KG , Becher Harald
Published: December 2014

In response to the 2008 position statement of the Collaborative Working Group of the British Society of Echocardiography and the Intensive Care Society, we describe a recently launched Fellowship in Critical Care Echocardiography at the John Radcliffe Hospitals Oxford. We discuss the educational principles underlying the design and ongoing evaluation of the curriculum.
The Challenges of HIV Disease in the Intensive Care Unit
Authors: Wittenberg Marc , Kaur Navkiran , Miller Rob F , Walker David A
Published: December 2014

HIV/AIDS continues to be a significant world health issue. Patterns of referral to intensive care units (ICU) have changed in parallel with advances in treatment. Proven Pneumocystis therapy and the introduction of antiretroviral drugs have increased life expectancy. Lower respiratory tract infection predominates as a reason for ICU admission. Pneumocystis jirovecii, TB, fungi and bacterial infections rank highly as respiratory pathogens and should be considered potentially causative. Neurological pathology and severe sepsis commonly necessitate ICU admission in this population. The timing of highly active antiretroviral therapy (HARRT) remains controversial in critically ill patients. Therapy may be difficult due to associated drug interactions, lack of intravenous drug formulation and known toxic side effects. Improvement in survival may have resulted as much from general improvements in ICU care as from advances in highly active antiretroviral therapy, notably lung protective ventilation strategies and approaches to the early recognition and management of sepsis. HIV infection is now considered a chronic illness and should not be seen as a bar to ICU admission. Many HIV-positive patients present with non-HIV related illness and can be expected to make as good a recovery as non-infected patients.
Posterior Reversible Encephalopathy Syndrome Secondary to Essential Hypertension
Authors: Nethercott Daniel , Clarke Sarah
Published: December 2014

We present the case of a young man who was previously well, but became unconscious while watching a football match. He was initially found to be hypertensive, with clinical and echocardiographic evidence of cardiac failure. He also had a fixed and dilated pupil. CT brain scanning was normal and it was only after a MR brain scan was performed that the diagnosis of posterior reversible encephalopathy syndrome was raised. Despite the name of the condition implying that neurological deficits are reversible, this patient had a prolonged period of disability requiring long-term rehabilitation.
Echocardiography in the Intensive Care Unit: Current Position, Future Directions
Authors: Morris Craig , Bennett Sean , Burn Steven , Russell Conn , Jarman Bob , Swanevelder Justiaan ,   NPOCUS Critical Care Echocardiography Working Group
Published: December 2014

There are many indications for the use of echocardiography in the critically ill and little consensus about how best to provide training for intensivists in its use. There are a profusion of opinions, courses and accreditation pathways available for training in the UK. The National Point of Care Ultrasound working group aims to facilitate learning and training in both echocardiography and ultrasound. In this article, an intermediate level of training suitable for most general UK-based intensivists, that provides more depth than focused resuscitation-based protocols but less depth than British Society of Echocardiography accreditation pathways, is proposed which, if endorsed by Royal Colleges and specialist societies, could be developed into a viable national training programme within five years.
Difficult Airway Trolleys for the Critical Care Unit
Authors: Jeanrenaud Paul , Girotra Vandana , Wharton Tim , Main Norman , Konuralp Rifat , Dempsey Ged
Published: December 2014

Airway management is paramount to patient safety in critical care. Intensive Care Society (ICS) standards state that all critical care areas should have a designated difficult airway trolley (DAT) equivalent to that found in operating theatres. We conducted a national survey to determine compliance with this guideline. Adult intensive care units (ICUs) were questioned about the presence of a DAT, its contents and airway training for clinicians. Two hundred and sixty-two ICUs responded to the survey (90%), of which 130 (50%) had a designated DAT. In 38 (29%), a difficult airway management algorithm was available. Capnography was unavailable in 51 (40%) units with a DAT. Compliance with ICS standards and guidelines should be encouraged with respect to DATs. DATs should be available for immediate use within the ICU. Staff should be trained in the use of DAT equipment and be familiar with a difficult airway management algorithm.
Sources of Occupational Pressure in Intensive Care and Potential Remedial Interventions
Authors: Kincey John , Lomax Michelle , Shelly Maire , Eddleston Jane , Morley Mike , Alexander Peter , Grout Claire
Published: December 2014

This study explores the views of intensive care medicine consultants and trainees concerning sources of occupational pressure, the perceived utility and practicability of organisational changes designed to reduce these, and the relevance of these findings for attempts to promote recruitment into and reduce attrition from the specialty. An anonymised postal self-report questionnaire was used to obtain the views of consultants and trainees, using a combination of specifically designed questions and an existing psychological measure. A wide range of sources of occupational pressure was identified, some generic and some more specific to occupational roles and location. Ratings of potential remedial occupational changes revealed that not all those considered to be most useful were considered to be practicable. Self-report data indicated some differences between consultants and trainees. The complex mixture of occupational pressures warns against simplistic introduction of potential interventions and confirms the need to consider different pressures at different career stages. Responsibility for identifying, implementing and evaluating such remedial occupational changes lies at individual, local, professional and managerial levels. It is suggested that the current methodology could be developed to explore similar questions among other medical specialties or healthcare professions.
Unrecognised Suction Failure Causing Tension Pneumothorax
Authors: Helling Simon , Benington Steve , Conway Daniel
Published: December 2014

We present the case of a patient who developed a bronchopleural fistula, which was treated with the use of a chest drain with application of suction. The patient significantly deteriorated clinically and developed a tension pneumothorax. After some delay, the wall suction unit was found to be blocked, thereby creating a closed system and causing a pneumothorax under tension. We discuss the safe application of suction to chest drains with particular reference to the use of the three-bottle system.
Global Clinical Networking and Pandemic Influenza
Authors: Walunj Ajit , Thomson Gail , Gent Nick , Dunning Jake , Brett Stephen
Published: December 2014

From June 2009 to February 2010, the Health Protection Agency hosted a clinical network including regular teleconferences, with the aim of sharing clinical experiences of the international participants about pandemic influenza. The minutes of the teleconferences over a two month period were analysed to identify clinical themes. A systematic literature search was then undertaken to identify peer-reviewed publications that either supported or refuted these themes. Observations relating to patient demographics, clinical features and clinical management were supported by published literature. Younger adults and children were more likely to be infected, but young adults were more likely to require intensive care. Obesity, pregnancy and asthma were confirmed as risk factors for severe influenza illness. Extra-pulmonary organ dysfunction was common, often requiring specific interventions. The benefit of certain ventilatory and non-ventilatory interventions remains unclear, although they were frequently used. This global clinical networking model facilitated the real-time exchange of valuable clinical information and provided the basis for clinical practice notes.
National Survey of the Use of Non-Invasive Respiratory Support for Acute Cardiogenic Pulmonary Oedema in Coronary Care Units in England
Authors: Holzmann Tim , Moore John , Sharman Michael
Published: December 2014

A telephone survey was conducted to assess the provision of non-invasive respiratory support available for the treatment of acute cardiogenic pulmonary oedema in England. Of 182 acute Trusts identified, data was obtained from 153 coronary care units (CCUs) (85%). At the time the survey was undertaken, more than a quarter of these CCUs did not have the facility to provide non-invasive respiratory support (NIRS) although these therapies were provided by the hospital intensive care units (ICUs) in 100% of hospitals that were contacted. In the CCUs providing non-invasive respiratory support, less than 20% audited their services; fewer than a third had a protocol for the management of acute cardiogenic pulmonary oedema and a management plan in the event of NIRS treatment failure — ie ‘do not resuscitate’ or escalation to higher levels of care — was mandatory in only 13% of units. This survey concludes that there is suboptimal provision of NIRS across CCUs in England adding to already heavily burdened critical care services. There is also widespread lack of clinical audit and management protocols, thus the effectiveness of available services is unknown.