bluuebunny/crossref_metadata_2025 huggingface dataset:
Concurrent Administration of Methylene Blue and a Selective Serotonin Reuptake Inhibitor: A Recipe for Serotonin Syndrome
Authors: Johnson Nicola , Soar Jasmeet , Robinson Stephen
Published: December 2014

This case report describes the precipitation of serotonin syndrome in a patient taking a selective serotonin reuptake inhibitor, by infusion of methylene blue dye during a parathyroidectomy procedure. Methylene blue acts as a monamine oxidase inhibitor, thus increasing levels of serotonin in the brain. The authors describe the diagnosis and management of serotonin syndrome and suggest that more caution be exercised in the use of methylene blue.
Palliative Care in the ICU
Authors: Cox Sarah , Handy Jonathan M , Blay Andrea
Published: December 2014

This is a review of the role of palliative care with intensive care patients. End-of-life care challenges are explored such as identifying patients at the end of life on ICU and involving patients, families and health professionals in decision-making. Ethical issues around withholding and withdrawing treatment are also discussed. Integration of palliative care into ICU practice is recommended to support the patient, family and ICU team during a patient's end-of-life care and in bereavement.
A Practical Approach to the Difficult-to-Wean Patient
Authors: Jackson Matthew , Strang Timothy , Rajalingam Yadhunanthanan
Published: December 2014

The difficult-to-wean patient represents 6% of the intensive care population, but consumes a third of resources. Such patients experience increased morbidity and mortality. Given the changing demographics of intensive care practice, this patient group is likely to grow. Hitherto management of the difficult wean is rarely debated, though there exists a clear demand for further exploration. Here we present often overlooked, modifiable patient factors to optimise the chance of weaning success. The mechanism of weaning, trouble-shooting, continuing and limiting treatment are subsequently explored.
Guidance on Occupational-Related HIV Post-Exposure Prophylaxis (PEP) in the Intensive Care Setting
Authors: Jones Ann-Britt , Hughes Amelia , Barton Simon
Published: December 2014

Healthcare workers are at risk for transmission of HIV via percutaneous injury (most commonly) or mucosal membrane exposure. Post-exposure prophylaxis provides a treatment strategy to prevent transmission of HIV among healthcare workers who have been exposed to a high-risk source. In this article, the likelihood of risk of transmission, issues surrounding testing source patients, and factors to consider when initiating post-exposure prophylaxis following occupational exposure to HIV in an intensive care setting are reviewed.
Acquired Haemophilia A – A Rare Cause of Bleeding
Authors: Patle Vidhi , Crawford Sarah E , Grace Richard J , Edwards Rhian E , Matthey Francis
Published: December 2014

This article reports a patient with acquired haemophilia who presented with life-threatening haemorrhage. Acquired haemophilia A is a rare autoimmune disorder caused by the development of an autoantibody to endogenous factor VIII. The diagnosis and management of the condition are reviewed. A high index of suspicion is essential for the accurate and prompt diagnosis of acquired haemophilia A, when the patient is bleeding and has an isolated abnormality in APTT.
Corticosteroid after Etomidate in Critically Ill Patients
Authors: Dalay Satinder Kaur , Jagannathan Sathyanarayanan , Chadwick Sean
Published: December 2014

In this prospective, single-centre, slightly underpowered, double-blind randomised controlled trial (RCT) with intention-to-treat analysis, use of moderate-dose hydrocortisone in etomidate-related adrenal insufficiency was not shown to reduce the proportion of patients with a cardiovascular Sequential Organ Failure Assessment (SOFA) score of 3 or 4.

Level of evidence: 2B (CEBM, low quality RCT)
The Australian Consultant Intensivist Transition (CIT) Course: Timely and Relevant for Intensivists Everywhere
Authors: Foot Carole , Hickson Liz , Vidhani Kim
Published: December 2014

This article aims to outline a new educational initiative on offer to newly qualified intensivists in Australasia, the Consultant Intensivist Transition (CIT) course. It is timely to consider the relevance of such a course in the UK as the recently formed UK Faculty of Intensive Care addresses the training needs of the intensive care specialist of the future.
Leucocytosis following Transfusion with Leucodepleted Red Cells to Non-Bleeding Critically Ill Patients
Authors: Saleh Ezzeldin , Walsh Timothy S
Published: December 2014

Previous studies have shown that transfusion of non-leucodepleted red blood cells can cause leucocytosis in recipients. A small study suggested that pre-storage leucodepletion removed this phenomenon, but has not been further substantiated. We explored whether recipient leucocytosis occurs when leucodepleted red blood cells were transfused to non-bleeding intensive care patients. We used routinely collected data for 95 transfusions in 54 patients. Overall, no leucocytosis was found on the first routine blood sample following transfusion (mean change 0.6 × 109/L; 95% confidence interval - 0.2 to 1.3; p=0.145). However, for the 32 transfusions in patients with normal pre-transfusion leucocyte count there was a clinically small but statistically significant leucocytosis following transfusion, unlikely to have occurred by chance (mean change 1.5 × 109/L; 0.5 to 2.5; p=0.005). No significant change was observed in patients with pre-transfusion leucocytosis. We found no relation between leucocytosis and storage age of red cells. Our data suggest that transfusions with leucodepleted red cells can increase leucocyte counts in recipients. The mechanism of this effect and its clinical importance are uncertain.
The Introduction of Intensive Care-Led Echocardiography into a Tertiary Care Unit
Authors: Alam Shirjel , Docherty Annemarie , Mackle Ian , Gillies Michael
Published: December 2014

The objective of this study was to evaluate the feasibility and impact of an intensive care-led trans-thoracic echocardiography (TTE) service replacing a cardiology-led service. Three intensivists were trained and accredited with the British Society of Echocardiography, and between 1st February and 1st August 2010 intensive care implemented a 24-hour scanning service. A prospective observational study was performed to examine the impact in our tertiary referral general intensive care unit. ECG, echocardiographic findings, technical difficulties and any changes in management made as a result of a TTE were recorded. Of 125 attempted scans, 120 patients had full studies (96%), four had limited studies (3%) and one was not possible. TTE changed management in 61 (49%) cases. This compares to only 57 scans performed in total in the preceding six months with a cardiology-led service. We conclude that intensive care-led TTE is feasible when carried out by trained staff, led to greater use of echocardiography and a change in management in almost half the patients studied.
Should Benzodiazepine Sedation be Delivered by Infusion or Bolus?
Authors: Hutchinson James , Harlow Georgina , Sinton David , Whitehouse Tony
Published: December 2014

Benzodiazepine sedation for mechanically ventilated patients in intensive care (ICU) is common practice worldwide. We performed a literature review to investigate whether benzodiazepine sedation is best delivered by continuous infusion or intermittent bolus. PubMed, Ovid and Cochrane databases were searched. Only four studies, involving 481 patients, were found. Three were randomised controlled trials and one was an observational cohort study; all used different benzodiazepines, sometimes in conjunction with opiates. The studies measured different outcomes including mechanical ventilation duration, length of ICU and hospital stay, quality and complications of sedation and mortality. Use of intermittent sedation or opiate boluses alone reduced mechanical ventilation duration, ICU and hospital length of stay. However such limited data means that the optimal mode of delivery for benzodiazepine sedation remains unresolved.
Human Albumin Solution Resuscitation in Severe Sepsis and Septic Shock
Authors: Leitch Andrew , Craig Gordon , Sadler Paul
Published: December 2014

There has been a recent resurgence of interest in the use of human albumin solution (HAS) for the resuscitation of critically ill patients. In particular, it may be beneficial for patients with severe sepsis and septic shock. We outline the evidence for the biological plausibility of this effect, perform a meta-analysis of randomised controlled trials comparing the effect of HAS with other fluid resuscitation on mortality in this group of patients and discuss the likely contribution of recently completed trials in this area. We included nine trials of 1,435 patients in the meta-analysis. Although HAS resuscitation was associated with a trend to lower mortality (relative risk 0.90, 95% confidence interval 0.79–1.02), we found that most trials reported to date are small and of variable methodological quality. The questions of a potential differential effect of dose on outcome and the pharmacological variability of HAS products have not been adequately addressed to date. We conclude that the routine administration of HAS to patients with severe sepsis and septic shock is difficult to justify on the basis of current knowledge.
The Impact of the National Institute for Health Research on Regional Intensive Care Research: A Case Study from Cumbria and Lancashire
Authors: Krige Anton
Published: December 2014

This article illustrates the regional experience of participation in research following the introduction of the National Institute for Health Research (NIHR) Comprehensive Local Research Networks (CLRNs) and the Critical Care Specialty Groups. Prior to this, research was focused in academic centres and tertiary hospitals. Clinicians in smaller regional hospitals had little opportunity or support to participate in clinical trials or other important studies. CLRNs were introduced to ensure that NHS research funding is spread widely throughout the NHS, ensuring all patients can potentially benefit from participation. This maximises research efficiency and results are likely to be more generalisable to the whole NHS, which may lead to wider and more rapid translation of positive studies into clinical practice.
Acute Liver Failure following Hepatic Resection: Incidence, Presentation, Prevention and Management in ICU
Authors: Jones Chris , Kelliher Leigh , Bigham Colin , Quiney Nial
Published: December 2014

The incidence of liver failure following liver resection has been reported to be between 8–32%, depending on the number of segments resected, the health of the patient and the incidence of hepatic ischaemic/reperfusion injury. This article outlines the evidence surrounding classification, prevention and management of this condition.
Atrial Fibrillation in the Intensive Care Setting
Authors: Malik Abdul , Candilio Luciano , Hausenloy Derek J
Published: December 2014

Atrial fibrillation (AF) is the commonest cardiac arrhythmia both in the general population and in the intensive care unit (ICU) setting. Its incidence continues to rise, affecting up to 10% of patients admitted to a general ICU and up to 50% of those admitted to a cardiac ICU. Uncontrolled AF has detrimental effects on the cardiovascular system, including heart failure, thromboembolic events, reduced quality of life and prolonged hospital stay. This article reviews the risk factors for developing AF, possible underlying mechanisms, clinical features and diagnosis, and focuses particularly on its management according to the latest guidelines with a specific focus on the ICU patient. We also discuss novel anticoagulants that will revolutionise the management of antithrombotic therapy in AF patients by replacing warfarin.
Eye Care in the Critically Ill: A National Survey and Protocol
Authors: Kam KY Ronald , Haldar Shreyar , Papamichael Esther , Pearce Kirsten CS , Hayes Michelle , Joshi Naresh
Published: December 2014

Sedated and ventilated critically ill patients often have inadequate eyelid closure and are susceptible to developing exposure keratopathy and microbial keratitis. Preventative measures reduce the risk of complications and visual loss. A telephone survey of all intensive care units in England was performed to elucidate the measures being used and their prevalence. Of 267 units, 217 participated (81%). Of these, 130 (60%) had an eye care protocol and 143 (66%) of all participating units formally assessed eyelid closure. The presence of an eye care protocol did not improve the likelihood of a unit assessing eyelid closure, a key component of the detection of patients at risk of ophthalmic complications; 66% of units with eye care protocols assessed eyelid closure formally, compared to eyelid closure assessment occurring in 65% of units that did not employ an eye care protocol. Most units used at least two protective methods per unit, the most popular being Geliperm application and Lacrilube. Self-reported complication rates in the last year were low, but only 13% of units audited eye-related complications. To improve eye care and replace current protocols, we propose a simple protocol encouraging vigilant eyelid closure assessment, administration of preventative therapy where indicated and referral if there is any corneal opacity or continuous exposure.
The Study of Harmful and Beneficial Drug Interactions in Intensive Care, Kerman, Iran
Authors: Rafiei Hossein , Abdar Mohammad Esmaeli , Amiri Masous , Ahmadinejad Mehdi
Published: December 2014

Since multidrug therapy is common in the intensive care unit (ICU), the risk of drug interactions is high. This study aimed to examine the prevalence of drug interactions and risk factors in patients who were admitted to ICUs. In a cross-sectional study, the medication flow sheet of 101 patients was investigated in terms of the number and the type of drug interactions. The Drug Interaction Facts reference text book (2010 edition) was used to determine the type and the number of drug interactions. In total, 609 potential drug interactions were found. The mean number of drug interactions per patient was 6.1 (SD=5.6). Of all observed drug interactions, 66.9% were classified as harmful and 33.1% beneficial. In terms of the nature of interactions, delayed, moderate, and possible were the most common types. The most frequent harmful interaction was between phenytoin and omeprazole (63 occasions). Critically ill patients are at a higher risk of drug interactions. Although 33.1% of the drug interactions were considered beneficial, medical teams should be aware that even beneficial interactions can have undesirable side-effects in the critically ill.
Fatal Systemic Embolism following Revision of Hip Arthroplasty: A Complication of Pulmonary Arteriovenous Malformation
Authors: Battle Charlotte , Dow Alasdair , Timperely John
Published: December 2014

A 72-year-old female patient who had a pulmonary arteriovenous malformation (PAVM) suffered systemic emboli causing pulmonary and cerebral infarction following the revision of an infected total hip replacement. Although not ultimately successful in this case, we detail the management of maintaining oxygenation and adequate cardiac output in a critically ill patient with a PAVM. We also discuss techniques that may be employed to minimise the shunt associated with the PAVM, with the aim of reducing the risk of systemic emboli.
Inhaled Nitric Oxide: A Review of the Action, Current Literature, and An Analysis of its Use in the NHS Today
Authors: McCartney Robert , Saha Shibaji , Rees James , Lawy Tom , Mosaheb Rishi
Published: December 2014

Nitric oxide is a potent vasodilator which when inhaled causes dilatation in the pulmonary vasculature. It is this action that has been studied in intensive care medicine, especially in relation to hypoxic vasoconstriction associated with acute respiratory distress syndrome (ARDS). The use of inhaled nitric oxide has been shown to improve ventilation:perfusion matching, and thus to improve oxygenation. This article reviews the chemistry and clinical properties of nitric oxide as well as its potential uses, clinical effectiveness and side effects. The authors also surveyed UK intensive care units to review the current prevalence of the use of inhaled nitric oxide. It was found that while the majority do not currently use inhaled nitric oxide in ARDS patients, it had still been used in 27% (n=61) of the departments surveyed.
Cardiogenic Shock and the ICU Patient
Authors: Tehrani Shana , Malik Abdul , Hausenloy Derek J
Published: December 2014

Cardiogenic shock is one of the most important complications of acute myocardial infarction (MI) and acute left ventricular failure (LVF). It threatens the life of 5–10% of patients with ST-segment elevation myocardial infarction (STEMI) particularly in the presence of inappropriately low peripheral vascular resistance. Cardiogenic shock results in poor tissue perfusion, end-organ damage and carries a high mortality risk. The goal of therapy is to prevent end-organ dysfunction and severe metabolic derangement by raising mean arterial blood pressure, which is achieved with the use of inotropes and vasopressors, often at the expense of tachycardia, elevated myocardial oxygen consumption and extended myocardial ischaemia. Current therapeutic approaches include early coronary artery revascularisation (which has significantly improved the survival rate), fluid resuscitation, inotropic support and mechanical circulatory support using intra-aortic balloon pumps or ventricular assist devices. In this article, we review the pathophysiology, diagnosis and management of cardiogenic shock.
A Survey of Current Practice and Attitudes Surrounding the Use of Ancillary Tests in the Diagnosis of Brainstem Death in Neurocritical Care Units in the UK
Authors: Barass Lynne , Sheridan Ashleigh , Mandersloot Gerlinde , Healy Marie
Published: December 2014

In the UK, the diagnosis of brainstem death (BSD) is confirmed by clinical testing. Guidelines regarding the timing of clinical tests after sedative drug use allow for variable interpretation. In some countries, ancillary tests are used as an alternative to clinical diagnosis. We conducted a survey of the use of ancillary tests within UK neurocritical care centres. Twenty-three centres had used or would consider using ancillary tests in addition to clinical tests where these could not be completed (eg, in cases of facial trauma). Nineteen centres had used or would consider ancillary tests when drug levels were unavailable. Twelve centres had used or would consider using ancillary tests to confirm BSD where raised drug levels precluded clinical testing. Following sedative drugs, timing of clinical testing varied considerably. While nine centres always measure thiopentone levels, six centres never do. There is considerable variation in UK opinion and practice. Further consensus is needed.
Ornithine Transcarbamylase Deficiency: Diagnostic and Management Challenges in the ICU
Authors: Watt Philip , lordache Sabina , Russell Philip
Published: December 2014

A young male patient presented with altered sensorium and rapid clinical deterioration following a short period of nonspecific illness and was subsequently diagnosed with ornithine transcarbamylase deficiency (OTCD). We discuss the pathophysiology of OTCD, the difficulties surrounding diagnosis and treatment, and highlight some of the controversies and general management issues of the disease.
Pulmonary Artery Aneurysm Caused by Aspergillus Pneumonia Presenting as an Endobronchial Mass Lesion
Authors: Cooper Victoria , Bera Rahul , Sherman Richard , Beed Martin
Published: December 2014

We present a case of pulmonary artery aneurysm (PA aneurysm) following Aspergillus fumigatus pneumonia treated by coil embolisation. Although rare, PA aneurysms have a high mortality rate with a large proportion of the cases reported being found at post-mortem examination. Aspergillus infection is known to result in aneurysms in immunocompromised patients and in patients with infective endocarditis. The case we report is unusual in that the patient was not obviously immunocompromised, and initially presented with a different pathology. Treatment by endovascular coil embolisation was successfully employed in this instance, allowing the patient to be weaned from ventilatory support. Although this is an unusual complication of Aspergillus pneumonia, the identification and successful treatment of pulmonary artery aneurysms requires a high-index of suspicion.
Intracranial Pressure Monitoring in Severe Traumatic Brain Injury
Authors: Fuller Gordon
Published: December 2014

Intracranial pressure monitoring with protocol-based management did not improve outcomes following severe traumatic brain injury compared to treatment based on imaging and clinical assessment.

Level of evidence: 1B− (an individual randomised controlled trial with wide confidence intervals)
Daily Interruption of Sedation and Nursing-Implemented Sedation Protocol in Mechanically Ventilated Adult patients
Authors: Keough Jamie , Nee Patrick
Published: December 2014

The combined use of daily interruption of sedation and a nursing-implemented sedation protocol targetting light sedation does not reduce duration of mechanical ventilation in adult ICU patients.

Level of evidence: 1B (RCT with a low risk of bias)
What the Intensive Care Doctor Needs to Know about Blast-Related Lung Injury
Authors: Mackenzie Iain , Tunnicliffe Bill , Clasper Jon , Mahoney Peter , Kirkman Emrys
Published: December 2014

Explosions are currently the primary cause of military combat injuries. A minority of civilian trauma is also caused by explosions. People hurt by explosion are likely to present with complex injuries. The aim of the article is to explain the mechanism underlying these injuries and the associated physiology to help the intensive care clinician manage these casualties properly. The generic term ‘blast injury’ is applied to a collection of injuries caused by explosion. Components of blast injuries have precise definitions relating to the elements of the explosion that caused the injuries: primary blast injury is due to a shock wave, secondary blast injury is caused by fragments and debris colliding with the victim and tertiary blast injury is due to the casualty being thrown against solid objects. Primary blast injury results in damage principally in gas-containing organs, eg the lungs (blast lung) and can lead to impaired pulmonary gas transfer and hypoxaemia. Secondary blast injuries are often penetrating and can lead to haemorrhage while tertiary blast injuries are often blunt and involve substantial tissue damage. Survivors of explosions in confined spaces are more likely to exhibit primary blast injury than those injured in open spaces. The current military approach to immediate management is to apply the C ABC principle (arrest catastrophic haemorrhage first and then deal with airway, breathing and circulation) to achieve Damage Control Resuscitation. Early administration of blood products (plasma as well as red cells) is advocated for those suffering significant haemorrhage. Initial resuscitation is hypotensive to minimise risk of dislodging nascent clots. However, if evacuation is protracted (longer than one hour) then consideration should be given to improving blood flow / oxygen delivery by adopting a revised normotensive blood pressure target to reverse the deleterious consequences of the hypotensive shock state. Animal studies have shown that titrating FiO2 to a target SaO2 of 95% can improve survival and ‘buy time’ during hypotensive resuscitation. Ventilator strategies should use a lung-protective approach with permissive hypercapnia if necessary. Blast casualties are often a challenging group of patients needing expert, tailored, care. Outcome can be good especially in young, otherwise fit, casualties with more than 96% surviving to ICU discharge, although this figure may be lower with a mixed civilian group.
A Survey of Intensive Care Unit Discharge Communication Practices in the UK
Authors: Wong Danny JN , Wickham Alex J
Published: December 2014

This survey into intensive care unit (ICU) discharge communication practices presents data from 60 responding units in the UK. Of these, 95% provide some form of written or verbal information to ward teams and 86.7% have Critical Care Outreach Teams, which provide the majority of post-discharge follow-up. Very little information is provided to patients, their relatives or GPs, with only 36.7% of units forwarding discharge letters to GPs, and 58.3% that do not formally provide discharge information to patients or relatives. These results highlight areas where the UK intensive care community can improve their communication about patients following discharge from ICU.
Worsening Oxygenation despite the Use of a Novalung iLa Membrane Ventilator
Authors: Garbarino James A , Girgirah Khaled , Dean Paul
Published: December 2014

We describe the case of a 31-year-old man admitted to the intensive care unit (ICU) with hypercapnia and hypoxia secondary to Aspergillosis, Pneumocystis jirovecii pneumonia and tuberculosis. The patient was treated with conventional lung-protective ventilation strategies. He subsequently had a Novalung® interventional lung assist membrane ventilator (iMV) inserted due to worsening hypercapnia. His condition initially improved; however eight days after insertion the iMV appeared to be associated with worsening oxygenation.
Prone Positioning in Severe Acute Respiratory Distress Syndrome (ARDS)
Authors: Gill Raj , Wong Tracy , Johnston Andy
Published: December 2014

Early use of the prone position for prolonged periods in severe ARDS is associated with a significant reduction in both 28-day and 90-day mortality (NNT 6).

Level of evidence: 1B (CEBM, RCT of good quality)
Expert Recommendations for Managing Acute Faecal Incontinence with Diarrhoea in the Intensive Care Unit
Authors: García C Bayón , Binks R , De Luca E , Dierkes C , Franci A , Gallart E , Niederalt G , Wyncoll D , Vaes P , Soderquist B , Gibot S
Published: December 2014

Acute faecal incontinence with diarrhoea (AFId) has been reported to affect up to 40% of patients in the intensive care unit (ICU). The clinical challenges of AFId include the risk of perineal skin breakdown and cross-contamination with nosocomial infections, such as Clostridium difficile. In addition, the management of AFId is a burden on nursing time and hospital resources. Despite these challenges, there is currently no standard way of managing AFId. To address this problem, an international panel of intensive care specialists was convened to discuss AFId management recommendations. The collective knowledge of the specialists combined with literature searches from online medical databases were used to create a set of guidelines together with an accompanying management algorithm to aid healthcare providers in deciding the most appropriate care for patients with AFId in the ICU. These guidelines have been specifically designed to take into account patient severity of illness and comorbidities, which coupled with common AFId-associated clinical complications, can influence management choices. A comprehensive review of current AFId management strategies, taking into account the spectrum of patients and hospital economic limitations, has been included as a reference guide. It is hoped that the wider adoption of these recommendations will be a step forward in improving the current management of AFId in the ICU.
The Cardiac Output Monitoring EvaluaTion –UK (COMET-UK) study
Authors: Ridley Saxon , Harrison David A , Walmsley Emma , Harvey Sheila , Rowan Kathy M
Published: December 2014

The aim of the Cardiac Output Monitoring EvaluaTion-UK (COMET-UK) study was to update reports of cardiac output (CO) monitoring use and to examine whether there is any association between the frequency of CO monitoring use in adult, general intensive care units and patient outcomes. Questionnaires were sent to all intensive care units in England, Wales and Northern Ireland (n=221) asking whether the unit had used CO monitoring in the last two years and, if so, to give details of average frequency of use and which CO monitors were available. The majority of units (n=100, 45.2%) used CO monitoring most days or a few times a week and 33 (14.9%) monitored CO every day (response rate 100%). The most commonly available methods were oesophageal Doppler (n=127, 57.5%), LiDCO (n=96, 43.4%) and PiCCO (n=92, 41.6%). There was no significant difference in risk-adjusted acute hospital mortality (p=0.25) or length of stay (p=0.48) across categories of frequency of use. However for ventilated vs non-ventilated patients and different quartiles of illness severity, there was an association between higher frequency of use and worse outcome among non-ventilated and lowest risk admissions quartiles. The COMET-UK study found that CO monitoring is in common use; however, there was no evidence that more frequent use of CO monitoring was associated with improved outcomes.
Pilot Study of Two Nurse-Led Weaning Protocols in Patients with Tracheostomies
Authors: Pattani Hina , Ehlers Mark , Girling Keith , Hird Caroline , Gardiner Dale
Published: December 2014

This is a pilot study, comparing two commonly-used weaning techniques in patients with a tracheostomy to establish if one technique resulted in shorter time to successful weaning. In a prospective, single-centre randomised, controlled trial, conducted in a 15-bed multidisciplinary intensive care unit, fifty patients mechanically ventilated for at least 48 hours and who had a tracheostomy inserted primarily for weaning purposes, were randomised to one of two weaning techniques: increasing periods of spontaneous ventilation, or reducing pressure support ventilation. Each technique was protocolised for implementation by the nursing staff and consisted of two stages: a weaning and a verification stage. This pilot study did not find a statistically significant difference in the length of time spent weaning when two nurse-led protocolised weaning techniques of increasing periods of spontaneous ventilation or reducing pressure support ventilation were compared in patients with a tracheostomy inserted primarily for weaning purposes. No safety issues were identified in either protocol.
Stabilisation and Transport of the Critically Ill Child
Authors: Dawes Joy , Ramnarayan Padmanabhan , Lutman Daniel
Published: December 2014

Since the Department of Health Report ‘Paediatric Intensive Care: A framework for the future’ in 1997, paediatric intensive care services have been centralised and 24-hour retrieval services developed. However, all hospitals admitting critically ill children must be able to resuscitate and stabilise prior to retrieval, and occasionally undertake the ‘time-critical’ transfers themselves. This article reviews the clinical and organisational skills involved in the retrieval process, and also suggests ways in which knowledge and skills can be maintained.
Still Preparing to Fail by Failing to Prepare? A Survey of Trainees' Experience of and Training in Interhospital Transfers
Authors: Paton Lia , Stenhouse Jude , Ruddy Jim , Howie Neil
Published: December 2014

Interhospital transfer of critically ill patients is a task frequently delegated to doctors-in-training. However, previous studies have shown them to be ill prepared for this task, prompting the inclusion of transfer medicine as a domain in both anaesthesia and intensive care curricula, though not as yet in emergency medicine. Given the change and variation in curricula, we surveyed anaesthesia and emergency medicine trainees in the West of Scotland to gauge their experience of and training in interhospital transfers. Our results showed trainees continuing to conduct solo interhospital transfers from an early stage in their careers without specific training. Redressing this shortfall in training is imperative, particularly as centralisation of services will require more frequent transport of greater numbers of critically ill patients by trainees. We speculate about why these deficits in transfer training persist and how they might be remedied, particularly given the proposed integration of specialist transport teams in Scotland.
Intensive Care Staff Attitudes to Deceased Organ Donation
Authors: Fenner Helen , Buss Charmaine , Gardiner Dale
Published: December 2014

Intensive care staff may harbour mixed emotions toward organ donation after circulatory death. We wished to compare these attitudes to donation after brainstem death, as well as explore attitudes toward Specialist Nurses in Organ Donation, who have been embedded into UK intensive care units since 2008. At the Mid-Trent Critical Care Network (MTCCN) annual conference, participants were asked, in small group workshops, to write down words they associated with donation after brainstem death, controlled donation after circulatory death and Specialist Nurses in Organ Donation. The words were later collated and assigned to have either a positive or negative association by three blinded individuals: a medical lawyer, a hospital communications manager and a final year medical student. One hundred and eight intensive care staff participated: 24 (22%) doctors, 61 (57%) nurses and 23 (21%) allied health professionals; 75 (69%) of the participants were female. Participants at the workshop offered a total of 211 words, 93 associated with donation after brainstem death (44%) and 118 (56%) associated with controlled donation after circulatory death. The numbers of positive and negative words associated with the two forms of donation were significantly different (p<0.001) (donation after brainstem death - 68 positive words, 25 negative words; donation after circulatory death - 29 positive words, 89 negative words). This difference remained significant (p<0.001) even after all words (n=48) that did not have unanimous agreement between the three blinded word assigners were excluded. Significantly more positive words (95) were attributed to the Specialist Nurse in Organ Donation than negative words (18) (p<0.001). We conclude that this group of intensive care staff were generally positive toward donation after brainstem death and the embedded Specialist Nurse in Organ Donation, but could harbour negative attitudes toward controlled donation after circulatory death. Only by continuing to address the opinions of healthcare professionals will donation after circulatory death become a usual and not an unusual event.
Increasing the Retirement Age in Intensive Care Medicine: Perception of the Effect on Patient Safety and Personal Health
Authors: Jones Ami , Walker Jason , Thorpe Chris
Published: December 2014

The government has recently increased the retirement age and as a result doctors are going to have to work longer. Intensive care medicine is a demanding specialty with significant on-call commitment, and this paper looks at the potential ramifications of this policy change on patient safety and personal health of intensivists. All consultants working in Wales with sessions in intensive care medicine were asked to complete a survey to ascertain their opinion on whether increasing age would affect patient safety or their personal health. If asked to work beyond the age of 60, 80% of respondents thought that patient safety would be jeopardised and 67% of respondents felt their personal health would be affected. Twenty-seven respondents (43%) have had or currently have health problems linked with work, and this correlates with the intensity of the on-call (p<0.004). Intensivists have substantial concern about whether increasing the retirement age is a realistic proposition in this specialty. If a consultant feels that he or she is not providing safe care it is important that the problem can be raised and addressed with the full support of the employers and the profession, and without penalty.
Rhabdomyolysis, Haemolytic Anaemia, Multi-Organ Failure and Colonic Stricture in a Patient with Salmonella Lohbruegge Gastroenteritis
Authors: Hughes Gareth , Davies Albert H , Szymczakowski Andrzej , McClements Stephen , Telford David , Nasmyth George , Alloush A
Published: December 2014

A 51-year-old man developed rhabdomyolysis and multiple organ failure following infection with Salmonella lohbruegge. This species was resistant to ciprofloxacin. After the patient was bacteria free, he continued to have symptoms due to adhesions and strictures until he had a defunctionning ileostomy performed surgically. According to the national reference laboratory, only two such cases have been isolated in the UK since 2004 in addition to this one. Since 1991, 12 human cases and five non-human cases involving snakes, lizards, shrimps and a chicken have been reported.
A Case of MDMA Toxicity with Unusual Clinical and Neuroradiological Features 2CO1
Authors: Narang Ravi K , Jadun Changez K. , Carr Bryan
Published: December 2014

The use of illicit substances is a growing concern in emergency medicine and results in an increasing number of hospital admissions and fatalities. MDMA (3,4-methylenedioxymethamphetamine) and LSD (lysergic acid diethylamide) are two such drugs which have similar physical and psychological effects and are normally detected in blood and urine testing within 24–48 hours of ingestion. We present a case of a 22-year-old man who was found unconscious and unresponsive. History suggested the ingestion of illicit substances within the past 24 hours; however, urine and blood toxicology screening was negative. The patient was initially diagnosed with and treated for meningoencephalitis; however, CSF findings were negative. During the patient's recovery, he developed upper motor neurone neurological signs with pupillary dilatation. An MRI scan of the head was performed which revealed unusual features consistent with toxic leukoencephalopathy, most likely as a result of illicit substance intake. Further history was acquired confirming that the patient had ingested MDMA and LSD. The patient's presentation and course of admission is presented, with the clinical features of MDMA toxicity and the finding of toxic leukoencephalopathy reviewed.
Intensive Care Follow-up in UK Military Casualties: A One-Year Pilot
Authors: Scott Timothy , Davies Matthew , Dutton Clare , Cummings Iain , Burden Bev , England Kaye , Wood Paul
Published: December 2014

Military casualties requiring intensive care were reviewed in a pilot follow-up clinic at approximately three to six months post discharge. All patients reviewed had suffered traumatic injuries in Afghanistan with a median New Injury Severity Score (NISS) of 41. Approximately 50% of casualties reviewed reported hallucinations while on ICU which were often intense and unpleasant. The predominant sedative agents used were morphine and midazolam. Occipital alopecia and pressure sores were reported as an unexpected finding in 35% of casualties. This appears to be permanent in 25% of cases and has required surgery in a small number of cases. Personality changes and anger are common and this cohort of patients can be sensitive to perceived stigmatising concerns regarding referral to psychiatric support services. Patient diaries, which were begun on intensive care in Afghanistan and continued through until discharge in the UK, were found to be very helpful. A significant proportion of clinic attendees thought the pilot clinic was helpful with a quarter of survey responders finding it very helpful. However, this was commonly based on the perception that they were helping the defence medical services improve delivery of care.
Heparin-Induced Thrombocytopenia: Is There a Role for Direct Thrombin Inhibitors in Therapy?
Authors: Scott Ian , Webster Nigel R
Published: December 2014

Heparin is widely used in the intensive care environment usually for thromboprophylaxis but also to facilitate extra-corporeal circuits such as renal replacement and ECMO. Heparin-induced thrombocytopenia (HIT) is a rare but extremely serious disorder. It is associated with significant morbidity and mortality. The diagnosis is often challenging particularly as thrombocytopenia can be caused by a number of other common conditions seen in intensive care. Unfortunately routine screening for HIT antibodies is not helpful as it is possible to have these but have no manifestation of the disease process. If the diagnosis of HIT is not considered and the patient does in fact have the disease process they are at risk of thrombotic episodes. This article reviews the pathophysiology of HIT and the challenges with making the diagnosis. We explore the role of newer anticoagulants that may have a role such as direct thrombin inhibitors.
Daily Interruption of Sedation in Mechanically Ventilated Adults without Tracheostomy
Authors: Keough Jamie , Nee Patrick A
Published: December 2014

The use of sedative and analgesic dugs is essential in intensive care. The lowest effective doses should be used for the shortest period of time in order to limit the risk of serious complications. Daily interruption of sedation (DIS) is one strategy that has been shown to reduce overall sedative drug use and to promote earlier liberation from mechanical ventilation. However, uptake has been limited because of concerns over accidental removal of devices, the additional human resources required to accomplish the sedation break and the large numbers of patients who may be ineligible for the intervention. Some recent studies have challenged the usefulness of DIS and have promoted instead, nurse-controlled protocols and the use of sedation scoring tools. This review examines the evidence for and against DIS in the adult ICU setting.
Wernicke's Encephalopathy: A Diagnosis to Consider Early in Patients with Learning Difficulties
Authors: Shah Nikunj , Combeer Elizabeth , Barker Robert
Published: December 2014

We report a fatal case of Wernicke's encephalopathy occurring in a patient with learning difficulties. Wernicke's encephalopathy is a condition most commonly associated with alcohol abuse, with a prevalence of 12.5% in patients with a history of alcohol abuse or dependence.1 The diagnosis is rarely considered in non-alcoholic patients. Here, we highlight that severe malnutrition following food refusal and a consequent thiamine deficiency can cause a fatal Wernicke's encephalopathy, where assessment of behavioural changes in our patient was complicated by the presence of her pre-existing learning difficulties. Early consideration of the possibility of Wernicke's encephalopathy permits prompt treatment with vitamin replacement therapy, which is usually well tolerated. This case highlights the need to consider the possibility of thiamine deficiency in any patient where malnutrition has occurred for whatever reason. Furthermore, Wernicke's encephalopathy should be considered in all patients with a reduced level of consciousness where no clear cause can be determined. Anaesthetists and intensivists should retain a high index of suspicion for the existence of thiamine deficiency when approaching patients with complicated medical histories that put them at risk of malnutrition.
The Optimum Location of Care for Traumatic Brain Injury Patients Admitted to Non-Specialist Hospitals
Authors: Fuller Gordon
Published: December 2014

Early secondary transfer and specialist care may offer a survival benefit for head injury patients with non-surgical lesions initially admitted to non-specialist intensive care units. However, results must be interpreted with caution due to a high risk of bias.

Level of evidence: 1B−, an individual cohort study with wide confidence intervals
Crystalloid or Hydroxyethyl Starch for Resuscitation in Intensive Care?
Authors: Banks Luke , Kirk-Bayley Justin
Published: December 2014

There are concerns about the safety of hydroxyethyl starch (HES) solutions for intensive care patients regarding possible increased mortality and increased incidence of renal impairment with associated morbidity. This large trial showed no change in primary outcome related to mortality, but an increased relative risk of 21% for the use of renal replacement therapy.

Level of evidence: 1B (individual RCT with narrow confidence intervals)
Oxygen Therapy in Critical Illness: Friend or Foe? A Review of Oxygen Therapy in Selected Acute Illnesses
Authors: Ridler Nick , Plumb James , Grocott Michael
Published: December 2014

In recent years there has been a gradual shift away from using uncontrolled high concentrations of inspired oxygen in some acute illnesses. Oxygen is perhaps the most frequently used drug in medicine, and understanding the balance of benefits and harms is essential knowledge for all anaesthetists and intensivists. While current teaching and practice emphasise avoiding hypoxaemia over concerns about hyperoxaemia, it may transpire that oxygen excess is more harmful than previously thought. As with many interventions in intensive care medicine, striving to achieve physiological normality may sometimes do more harm than good, and tolerance of abnormal values may on occasion be in patients' best interests. Incorporating Single Best Answers (see page 197: answers on page 237).
Comorbidity and Intensive Care Outcome — A Multivariable Analysis
Authors: Docking Robert , Mackay Andrew , Williams Claire , Lewsey Jim , Kinsella John , Booth Malcolm
Published: December 2014

Decisions regarding admission to intensive care are made considering both the physiological state of the patient and the burden of comorbidity. Despite many retrospective cohort studies looking at isolated comorbidities, there has been little work to study multiple comorbidities and their effect upon intensive care outcome. In this retrospective cohort analysis, detailed comorbidity and demographic data were gathered on 1,029 patients from the West of Scotland and matched to both unit and hospital mortality at 30 days. Logistic regression was performed to investigate the factors associated with death within 30 days at both hospital and unit level. Variables with a p-value <0.25 at the univariable level were considered in a multivariable model. Variable selection for the multivariable modelling was carried out using backward selection and then replicated using forward selection to check for model stability. A modelling tool was constructed for both unit and hospital mortality at 30 days. This modelling has shown significant odds ratios for hospital death for alcoholic liver disease (OR 4.83), age (1.03), rheumatological diseases (1.93) and functional exercise tolerance prior to admission (3.08). Results from this work may inform a national prospective study to validate the modelling tool on a wider population.
Observational Study of the Effect of Heparin-Containing Flush Solutions on the Incidence of Arterial Catheter Occlusion
Authors: Tully Redmond P , McGrath Brendan A , Moore John A , Rigg Jonathan , Alexander Peter
Published: December 2014

The National Patient Safety Agency (NPSA) highlighted potential dangers associated with arterial lines in 2008, recommending the use of saline-only flush solutions. The incidence of catheter thrombosis appeared to increase following the implementation of this guidance in some units. The objective of the current study was to observe local practice regarding the use of heparin in arterial catheter flush solutions, and subsequent arterial catheter occlusion rates. This was an observational study in which data were collected prospectively from 445 catheter insertions in unselected intensive care patients in eight member hospitals of the Association of North Western Intensive Care Units (ANWICU). Catheters flushed with heparinised solutions had a significantly increased median lifespan of 102 hours versus 72 hours for saline-flushed catheters (p<0.01). The likelihood of line blockage was significantly decreased in the heparin group (7.9%) compared with the saline group (41.2%, p<0.0001). Our results suggest that routine use of heparinised flush solutions is associated with increased catheter lifespan and reduced catheter thrombosis. We believe that there is justification for an adequately powered, randomised controlled trial. Current NPSA guidance may need to be reviewed.