bluuebunny/crossref_metadata_2025 huggingface dataset:
Do Selective Digestive Decontamination (SDD) and Selective Oral Decontamination (SOD) Affect Mortality?
Authors: Price Richard
Published: December 2014

In this cluster-randomised, multicentre study, topical plus systemic SDD and SOD reduced the incidence of death, with numbers needed to treat of 29 and 34, after statistical correction for baseline imbalance due to the cluster design of the study.

Level of evidence: 1++ (RCT with very low risk of bias)
Sedation: Titration vs Daily Cessation
Authors: McAree Simon
Published: December 2014

A sedation algorithm designed to keep patients at RASS −2 to −3 out-performed daily interruption of sedation, with a reduction in mechanical ventilator days, length of ICU stay, and hospital length of stay.

Level of evidence: 1− (RCT with a high risk of bias)
Survey of Percutaneous Tracheostomy Practice in UK Intensive Care Units
Authors: Sarkar Som Nath , Kelly Andrew , Townsend Roger
Published: December 2014

In order to assess current practice of percutaneous tracheostomy (PT) in UK intensive care units (ICUs), we created a web-based survey by e-mail invitation to the clinical directors of 184 ICUs taking part in the ICNARC case-mix programme. The response rate was 46% (n=85). Most units performed 100 or fewer PTs each year. Just over half, 55.3%, had access to resident on-site surgical backup with ENT being the most common specialty providing this. Nearly one third, 30.6%, performed PTs out of routine hours; 30.6% used ultrasound to visualise potential problematic vessels. Bronchoscopy was used by 81.7% of units for all PTs performed, and conical dilation was the most popular technique. Fifteen units, 8.2%, did not routinely perform chest X-ray after PT insertion, but 49.4% of respondents did not feel that chest X-ray was mandatory after routine uncomplicated PT insertion. Despite certain trends in practice, there is still disparity in the practice of PT among ICUs in the UK. Ultrasound examination for problematic blood vessels prior to PT should be considered, bronchoscopy should be readily available and the use of routine chest X-ray after uncomplicated PT insertion should be questioned.
Management of Inhalational Injuries in UK Burns Centres – a Questionnaire Survey
Authors: Prior Kate , Nordmann Giles , Sim Ken , Mahoney Peter , Thomas Rhys
Published: December 2014

Management of inhalational burn injuries in UK specialist centres varies widely, according to this survey, which was carried out in 2008. Areas investigated included the use, or not, of therapeutic bronchoscopy, the use of nebulised agents, ventilatory support strategies and pharmacological treatments used to decrease the incidence of pneumonia. Evidence-based guidelines do not currently exist. The survey has led to setting up a National Consensus Working Group to develop nationally agreed guidelines.
Changes in Management of Septic Shock in Scottish Intensive Care Units after the Publication of the Surviving Sepsis Campaign Guidelines 2008
Authors: Dalchow Stephan , Binning Alexander
Published: December 2014

The 2004 guidelines of the Surviving Sepsis Campaign (SSC)1 for the management of severe sepsis and septic shock included recommendations about glucose control, the use of recombinant human activated protein C (rhAPC) and intravenous steroid replacement, based on original trials by van den Berghe and Annane in 2001 and Bernard (PROWESS) in 2002. In 2008, the SSC revised the international guidelines2 to reflect the results of recent trials (VISEP, CORTICUS, ADDRESS, RESOLVE). Some of these studies completely or partially contradicted results of the earlier trials. We conducted a questionnaire survey of all intensive care units (ICUs) in Scotland six months after publication of the 2008 SSC guidelines to assess current practice.
Oral Hygiene Practices in Scottish Intensive Care Units – a National Survey
Authors: Kearns Rachel , Booth Malcolm
Published: December 2014

Ventilator-associated pneumonia (VAP) is associated with prolonged intensive care (ICU) stay, increased mortality and costs. Although oral hygiene may help prevent VAP, there is little data about practice in ICU. Therefore a telephone survey of oral hygiene practice in Scottish ICUs was undertaken. All 24 respondents (100% of units) thought that providing oral hygiene care was a worthwhile use of nursing time in the ventilated ICU patient. Fifty-four percent of respondents recognised the importance of oral hygiene in the prevention VAP. Other benefits of oral care cited were maintenance of patient comfort and dignity, and of tooth, gum and oral mucosal health. Most ICUs also felt that further training would be beneficial. Oral hygiene is recognised as having an important role in patient comfort. There is still a lack of evidence concerning the place of oral hygiene care in preventing nosocomial infection in mechanically ventilated patients, as highlighted in the recent NICE guidelines.
Introducing Photo Diaries for ICU Patients
Authors: Jones Christina
Published: December 2014

Frightening memories of intensive care, particular delusional memories, such as hallucinations and nightmares, have a powerful adverse effect on psychological health of former intensive care unit (ICU) patients. A diary of the time on ICU can help patients understand what has happened and put any unpleasant memories they may have from their experience into context. Whiston Hospital has used patient diaries since 2002. This article describes how to establish a diary service and how diaries can be used to help patients understand their ICU experience.
Quality of Patient Handover on Intensive Care Units in Northwest England
Authors: Bannard-Smith Jon , Booth Chris , Saha Bhaskar , Washington Steve
Published: December 2014

Continuity of patient care in the intensive care unit is dependent on reliable and accurate handover. The introduction of shift working for junior doctors as a result of the working time directive has resulted in a minimum of two handovers between medical staff in each 24-hour period. Structure and method of handover has been shown to critically influence the transfer of clinical information vital to the continuity of patient care. We conducted a telephone survey of the intensive care units in the north-west of England to establish details surrounding the methodology of handovers which are currently being used. We established that handovers in our region are generally occurring in a structured manner, but that the quality of handover, information transmitted and personnel present is varied. We advocate the use of a computer-based handover sheet to increase the accuracy of the handover process.
The Impact of Trust Study Days on Organ and Tissue Donation among Critical Care Staff
Authors: Sharp Tracy Anne
Published: December 2014

The UK has one of the lowest rates of organ donation in Western Europe. Several barriers to the donation process have been identified. Among these are lack of knowledge, failure of staff to identify potential donors and feeling that it is someone else's responsibility to request for donation. Evidence suggests that educational programmes covering issues regarding organ and tissue donation enhance knowledge and confidence in the organ donation process and ultimately increase the number of potential donors. In 2002, Bolton NHS trust made changes aiming to increase donor rates. Trust study days were introduced, aiming to educate staff about aspects of donation. Since then, Bolton has had a significant increase in donor rates. The purposes of this audit were to assess present levels of knowledge and attitudes about organ and tissue donation and to see whether the introduction of trust study days has made a positive impact amongst critical care staff. The findings of this audit are encouraging, showing a positive impact on both staff knowledge and attitudes towards donation and reflecting a change in culture within the trust.
Using Low-Dose Methylprednisolone in Early ARDS Leads to a More Rapid Improvement in Lung Function
Authors: Appleton Richard
Published: December 2014

Treating ventilated patients within 72 hours of the diagnosis of acute respiratory distress syndrome (ARDS) with prolonged low dose methylprednisolone leads to a more rapid improvement in lung function and may reduce the duration of mechanical ventilation and ICU stay.

Level of evidence: 1− (RCT with a high risk of bias)
Intensive versus Conventional Glucose Control in Critically Ill Patients
Authors: Tanner Oona
Published: December 2014

Intensive glucose control with a target blood glucose 4.5–6.0 mmol/L increases the risk of death at 90 days (number needed to harm (NNH)=38) and severe hypoglycaemia (NNH=16).

Level of evidence: 1+ (RCT with a low risk of bias)
Broncho-Abdominal Fistula: Making the Diagnosis and Managing the Patient
Authors: Cook Caroline J , Weston Antony , McCallum Duncan
Published: December 2014

The diagnosis and management of broncho-abdominal fistula in critically patients is difficult, with various treatment options including medical, surgical, ventilatory strategies and drainage systems. We report the case of a 58-year-old male patient who presented acutely with systemic sepsis 41 days after undergoing an elective laparoscopic cholecystectomy. The patient underwent a 34-day course of intensive care treatment during which the diagnosis of a broncho-abdominal fistula was made using a simple technique previously undescribed in the critical care literature. The case was subsequently managed successfully following the introduction of high frequency oscillatory ventilation (HFOV) as the principal mode of respiratory support. We describe the unusual presentation, the method of diagnosis and the subsequent management of this case using HFOV.
Chemical Burns and Multiorgan Failure following Acute Ingestion of White Spirit: A Case Report and Review of the Literature
Authors: Harb Ayad , Harb Ziad , Bromilow James
Published: December 2014

Organic solvents are chemically different compounds with one common feature: they dissolve fats, oils and resins, which makes them widely used in industry. Organic solvents are used in paint and lacquer industries, in the production of pesticides, plastics, explosives and in the pharmaceutical industry. The most common household solvent is white spirit, used as a paint remover. We report a case of acute white spirit ingestion causing multiorgan failure and a prolonged intensive care unit admission. Such a case has not been documented previously and highlights a number of diagnostic and therapeutic considerations. The patient also represents the first reported case of chemical burns from erosive diarrhoea secondary to white spirit ingestion.
Payment by Results and Adult Critical Care
Authors: Eddleston Jane , Young Keith
Published: December 2014

This article outlines the present position regarding Payment by Results (PbR) for adult critical care services. It does not include paediatric or neonatal services because, although very similar processes are being followed for these services, the issues raised and the timetable that applies are different to those for adult services.
Cardiopulmonary Exercise Testing — A Survey of Current Use in England
Authors: Simpson Joanna C , Sutton Hannah , Grocott Michael PW
Published: December 2014

Cardiopulmonary exercise testing (CPET) is an objective method of evaluating integrated cardiopulmonary function. Increasingly, it is being used for perioperative risk assessment. This survey was performed between October and December 2008 to identify where and how CPET is being used for perioperative risk assessment in England. Direct telephone contact was made with the Department of Anaesthesia in 154/173 (89%) of NHS Trusts in England in order to ascertain the availability of a CPET service. One hundred and fifteen (66%) Trusts confirmed whether or not they have a CPET service −30 (17%) Trusts have a CPET service and 12 (7%) are in the process of setting one up. These Trusts were sent a nine-question survey, which was completed by 15 Trusts. Criteria for selecting patients for CPET testing included type of surgery, age and co-morbidities. All trusts use anaerobic threshold (AT) values to identify patients at risk of adverse outcome, though many also used additional variables including peak oxygen consumption, ventilatory equivalents for carbon dioxide, ventilatory equivalents for oxygen, oxygen pulse, oxygen consumption/power slope and breathing reserve. Different numerical threshold values were used in different centres. Patients identified as high risk were managed in a variety of ways, including referral for specialist advice, modifying or cancelling surgery, modified perioperative care and augmented postoperative care (in a level 2 or 3 environment). This survey clearly highlights significant inconsistency in the use of CPET for perioperative risk assessment and suggests that some standardisation of practice may be of value.
Iatrogenic Anaemia in the Critically Ill: A Survey of the Frequency of Blood Testing in a Teaching Hospital Intensive Care Unit
Authors: Astles Tim
Published: December 2014

Anaemia in the critically ill remains a contentious issue. Despite adoption of lower haemoglobin levels as transfusion triggers, many patients on intensive care units (ICUs) still require blood transfusions during their illness. One factor that contributes to the critically ill becoming anaemic is regular phlebotomy. Over a two week period, all blood tests performed on patients in a busy, teaching hospital ICU were surveyed to allow calculation of the total volume of blood that had been taken. On average, 52.4 mL of blood was taken per patient per day, and 366.8 mL per patient per week. The most frequently performed tests were arterial blood gas analyses, performed on average 5.8 times per patient per day (range 0–21 times per day). Arterial blood gas analysis alone accounted for taking of 29 mL of blood per patient per day, ie 203 mL per patient per week. Several methods for reducing the amount of blood taken from ICU patients have been identified and discussed. By implementing some of these simple changes in our institution, it would be possible to reduce the volume of blood taken by 43%.
Application of Induced Hypothermia for Neuroprotection after Cardiac Arrest: A Systematic Review
Authors: Shukla Viplaw Kumar
Published: December 2014

The dismal outcome after cardiac arrest calls for novel therapeutic approaches. Therapeutic hypothermia is a promising therapeutic modality. In this article we review the evidence for therapeutic hypothermia, for the best methods for cooling available and for the safety of therapeutic hypothermia.
The Current Role of the Pulmonary Artery Catheter in Critical Care: A Case Report and Review of the Literature
Authors: Zochios Vasileios , Gopal Shameer
Published: December 2014

The clinical use of the pulmonary artery catheter (PAC) has changed the modern practice of intensive care medicine. However, the effect of invasive haemodynamic monitoring on patient outcome remains uncertain. We report an unusual case of malposition of a PAC in the left internal mammary vein and we discuss the role of this monitor in the intensive care setting. Overall, the literature does not suggest a positive effect of PAC use on patient outcome. It has been suggested that PAC insertion may be of little benefit unless linked to specific therapies which may alter outcome. It is essential to understand the capabilities and limitations of the PAC in order to minimise potential complications and maximise benefits.
Modification of a Non-Invasive Positive Pressure Ventilator Circuit to Collect Exhaled Gases
Authors: Daykin Andrew P , Glinister Michael G
Published: December 2014

A modification of the expiratory port of the BiPAP™ (Respironics, Inc.) non-invasive ventilator circuit is described, which collects all expired air, and allows safe disposal of potentially infective exhalations distant from patients and staff.
Heparin-Induced Thrombocytopenia in the Intensive Care Unit
Authors: Hall Alison , Thachil Jecko , Martlew Vanessa
Published: December 2014

Heparin-induced thrombocytopenia (HIT) occurs following an immune reaction to the administration of heparin, which results in increased platelet activation and thrombocytopenia, and lead to arterial and venous thrombosis in untreated cases. It may be considered as an idiosyncratic, drug-induced reaction in which heparin injections result in the formation of complexes with platelet factor 4 (PF4), triggering an antibody-mediated reaction in certain individuals. Low platelet count in this instance is secondary to platelet aggregation and can lead to thrombotic complications by vascular occlusion and other mechanisms. Early recognition of this complication is essential to prevent life- and limb-threatening thrombosis. Therefore, it is important that intensive care physicians who administer heparin in different forms are aware of this potential adverse event and follow a regular plan in monitoring the platelet count while the patient is on heparin. In a patient whose platelet count falls while on heparin, when no other diagnostic possibilities can easily explain it, immediate withdrawal of any form of heparin and commencement of an alternative anticoagulant is necessary until the diagnosis of HIT is confirmed or excluded. At the same time, it is important that over-diagnosis of HIT is not made to avoid unwanted bleeding complications from the alternative anticoagulants. This review outlines the pathophysiology, diagnosis and management of HIT with a focus on the intensive care setting.
Antibiotic Prophylaxis for Percutaneous Tracheostomy: A Survey of Current Practice in the UK
Authors: Hanna-Jumma Sameer , Higgins David , Kinnear John , Wright Melanie
Published: December 2014

Percutaneous tracheostomy (PT) is a commonly-performed invasive procedure in intensive care units. Infections (including bacteraemia and nosocomial pneumonia) are recognised complications that occur following PT. The recently published document ‘Standards for care of adult patients with temporary tracheostomies' produced by the Intensive Care Society UK (ICS) made no recommendations regarding antibiotic prophylaxis (AP) for PT, and we were unaware of whether AP is used for this procedure in the UK. We therefore conducted a survey of the current practice in 130 critical care units; 65 responded. None gave antibiotics for routine PT, but in the presence of known colonisation with methicillin-resistant Staphyloccocus aureus (MRSA), six units (9%) would give antibiotic prophylaxis. Only three units (5%) had a policy for antibiotic prophylaxis. Twenty-six critical care units (40%) reported infectious complications occurring following PT. Despite a high level of awareness among clinicians that PT is associated with a significant risk of infective complications, only a small number administer AP prior to PT insertion even in patients colonised with MRSA and those with positive sputum cultures. The majority of units do not have a policy or guidelines for administration of AP prior to PT despite the fact that administration of appropriate antibiotics has been shown to reduce perioperative infectious complications for this procedure.
Survey of the Use of Capnography in UK Intensive Care Units
Authors: Thomas Antony N , Harvey Daniel
Published: December 2014

Capnography is not currently part of standard monitoring in intensive care practice in the UK. In order to investigate how widely capnography is used and reasons for lack of use, we sent a survey to lead clinicians of adult intensive care units. The response rate was 61%; 45% of responding units did not have the facility to monitor carbon dioxide at all funded bedspaces. Approximately 30% of units were covered at least part of the time by doctors who did not have advanced airway skills. Reasons for not using capnography included its lack of correlation with arterial blood gases and the fact that capnography is not 100% sensitive or specific for the diagnosis of airway misplacement. Capnography should be used during intubation to confirm airway placement in the intensive care unit.
The Use of Carnitine Rather than Renal Replacement Therapy for Sodium Valproate Poisoning
Authors: Leitch Andrew William , Williams Matthew
Published: December 2014

Valproate toxicity can be complicated by the development of hyperammonaemia, which can cause cerebral oedema and encephalopathy. We report the successful management of a case of valproate overdose using carnitine and review the metabolic pathways responsible for its therapeutic effects.
Procalcitonin to Guide Duration of Antibiotic Therapy in Intensive Care Patients: A Randomised Prospective Controlled Trial
Authors: Gopal Vijayakumar , Nallapareddy Sridhar
Published: December 2014

In surgical intensive care patients, monitoring of procalcitonin (PCT) is a helpful tool for guiding antibiotic treatment when compared with a standard eight day regimen. This may contribute to an optimised antibiotic regimen with beneficial effects on microbial resistance and costs in intensive care medicine.

Level of evidence: 1+ (RCT with a low risk of bias)
Lawyers in Intensive Care: Introducing an Acute Legal Service for Patients with Critical Illness
Authors: Eynon C Andy , Dinsmore Andrew , Dench Stuart
Published: December 2014

Following admission to the intensive care unit (ICU), patients or their relatives may need legal advice. This is a retrospective review of the impact of an in-house legal service able to provide legal advice acutely, in a specialised 13-bed neurosciences ICU in a University Hospital over a two and a half year period. All patients admitted to the ICU were considered. Consent for approach by the legal service was taken from the patient if possible. If not possible, assent was obtained from the next of kin. Solicitors were available for one afternoon per week on the ICU or within one day in emergency situations. The amount of time spent in discussion of non-compensation issues arising as a result of admission was measured as well as the time spent identifying potential claims for compensation against a third party and resulting in legal firms being instructed to pursue claims. One hundred and nine legal audits were undertaken. Non-compensation advice was provided in all cases. Possible compensation claims were identified in 63 cases. Of these, the advising firm of solicitors was instructed in 14 cases. Significant numbers of ICU patients and their families have legal issues arising as a result of acute hospitalisation. In many instances, these are not dealt with while the patient is seriously ill. Early identification and management of these issues helps to relieve the anxiety experienced by families.
Acid-Base Correction: A Case Report and Review of the Literature
Authors: Jones Mike Ward , Williams Matthew
Published: December 2014

Metabolic alkalosis is a common acid-base abnormality in hospitalised patients, though not frequently life-threatening. We present a case of severe metabolic alkalosis complicating colorectal surgery, which necessitated treatment with intravenous hydrochloric acid. The pathophysiology and treatment of severe metabolic alkalosis are reviewed, with an emphasis on the risks and benefits of hydrochloric acid use.
Anticoagulant Use in Renal Replacement Therapy in the Mid Trent Critical Care Network: A Survey of Practice
Authors: Sharman Andrew , Gardiner Dale , Girling Keith
Published: December 2014

Anticoagulant drug use is one of the methods employed to prolong filter life during renal replacement therapy in the critically ill patient. In the Mid Trent Critical Care network, a variety of anticoagulant regimens are used with varying efficacy. This is a retrospective survey of anticoagulant regimens, comparing mechanical filter life, blood product use and documented complications in the five largest units using renal replacement therapy in the region, and to evaluate how effective our regimens were compared to standards defined in the medical literature.
Remifentanil Sedation: A Five Year Retrospective Case Series Focusing on its Role in Non-Invasive Ventilation
Authors: Smallwood Nicholas , Peringathara Biju , Twigg Steven
Published: December 2014

This is a retrospective observational study of practice in the intensive care unit (ICU) of a 700-bed district general hospital in the UK, which aims to describe the indications for remifentanil sedation in current critical care practice, with particular reference to its use in patients who are unable to tolerate non-invasive ventilation (NIV). Controlled drug records were analysed over a five year period and each prescription of remifentanil matched against patient records to determine the indication, dose and duration of use, alongside significant clinical events. Where patients received NIV, the duration of use and days of remifentanil sedation (if appropriate) were recorded. During the study period, a total of 3,259 patients were admitted to the ICU, of whom 469 (14.4%) received remifentanil. The majority of patients, n=286 (61.0%) received remifentanil while not intubated; for 232 (81.1%) it was prescribed to enable them to tolerate NIV. In this group, the mean duration of remifentanil infusion was 2.55 days, with the mean dose 4.55 mg/day, equivalent to approximately 0.04 μg/kg/min. Of the patients who were intubated, the most common indication was as part of a weaning strategy, the patients having previously been given longer acting agents. Due to its unique pharmacokinetic profile, remifentanil is used in a variety of specific clinical situations in our practice, in both intubated and non-intubated patients. In particular, we provide data to confirm its role as a safe and effective sedative in patients who are unable to tolerate NIV.
Phaeochromocytoma Crisis Presenting under Anaesthesia with Profound Left Ventricular Failure — Successful Treatment with Intra-Aortic Balloon Pump
Authors: Carey Michelle , Carter Jim , Nesbitt Ian
Published: December 2014

A patient presented with a phaeochromocytoma crisis during routine anaesthesia for minor ENT surgery. The ensuing cardiac arrest and profound left ventricular failure were successfully treated with an intra-aortic balloon pump until alpha blockade with phenoxybenzamine took effect. The rapid diagnosis of phaeochromocytoma and management of phaeochromocytoma crisis are reviewed.
Analysis of Consistency in Intensive Care Unit Consultants' Decision Making in Clinical Practice
Authors: Ridley Saxon
Published: December 2014

This study examined whether there was significant variation in the rate at which different intensive care unit (ICU) consultants accept unplanned referrals to critical care. Over 2.75 years, 1,292 unplanned referrals were admitted to the ICU at Glan Clwyd Hospital, representing an average rate of one unplanned admission every 18.6 hours. There was significant variation in the rate at which consultants accepted unplanned referrals, ranging from 0.99 to 1.83 admissions per 24 hours (p = 0.0039). There was also a significant difference between the rate of acceptance during normal working hours and outside these hours (p <0.001). Some of this variation was associated with differences in severity of illness, whether the patient was accepted in or out of hours and the number of beds used each day. Using rates of acceptance of unplanned admissions could be a useful measure of an ICU consultant's performance.
Delays in Transfer Times for Patients with Extradural Haematomas in Greater Manchester
Authors: Booth Chris , Datta Devjay , Protheroe Richard
Published: December 2014

Decompression surgery for acute extradural haematoma (EDH) should be completed within 240 minutes of the onset of significant symptoms. Previous studies have shown that this time target is rarely met. We investigated all EDH patients requiring surgical intervention who were referred to Salford Royal Foundation Trust in a six-month period to establish the causes of delay in definitive treatment. The study showed a median time of 384 minutes (range 198–704) from admission to the recipient emergency department to the commencement of surgical decompression. Analysis of the timeline of treatment showed that the attainment of initial CT scan and preparation for transfer were the primary factors delaying definitive treatment. We recommend altering the approach to certain key processes, namely attainment of CT, the referral process and the preparation for transfer, in order to achieve the 240-minute target.
Current Trends in Cardiac Output Monitoring in UK Intensive Care Units
Authors: Labib Ahmed , Singh K Suresh , Krishnan Kandasamy , Dhillon Parveen , Mallick Abhiram
Published: December 2014

The current practice of cardiac output monitoring in critically ill patients was surveyed in 226 adult intensive care units in England and Wales. The response rate was 76% (n=171). Among the responding units, 96% used cardiac output monitoring routinely and 60% had access to more than one monitoring technique. Pulmonary artery catheters were no longer used in one third of the units. More than half of the units (57%) had moved to less invasive techniques. Oesophageal Doppler was used by 35% of the responding units, Lithium indicator Dilution Cardiac Output (LiDCO) by 22% and Pulse-induced Contour Cardiac Output (PiCCO) in 20%. Sixty-one percent of the lead clinicians felt that cardiac output monitoring may alter patient outcome. Two-thirds of units (68%) use superior vena cava oxygen saturation (ScvO2) during initial resuscitation of patients with severe sepsis or septic shock.
Bodybuilding — A Remarkable Recovery
Authors: Kidd Lawrence R , Hepburn David P , Middleton Linda A
Published: December 2014

A 43-year-old bodybuilder with a history of anabolic steroid abuse was admitted having been found unresponsive. Examination revealed antecubital fossae contusions but was otherwise unremarkable, as were all initial investigations. Deteriorating Glasgow Coma Score necessitated tracheal intubation. Early attempts at weaning from mechanical ventilation coincided with marked haemodynamic instability and decerebrate posturing to pain with upgoing plantar responses. The patient subsequently became almost completely areflexic, although corneal reflexes were preserved and spontaneous breathing remained. An electroencephalogram showed evidence of a non-specific toxic or metabolic encephalopathy, despite a negative toxicology screen and consistently normal imaging. In the following weeks, a gradual spontaneous improvement occurred. Fourteen weeks after admission, the patient walked out of hospital having made an almost complete recovery. Possible causative factors are discussed, as well as the complications and challenges of managing bodybuilders abusing anabolic agents. These patients require both vigilance and an open mind, as the potential for complications is varied and potentially multi-systemic.
The Use of Intralipid in the Management of a Mixed Overdose
Authors: Orr Karen , Bailie Ronald
Published: December 2014

A 34-year-old man took a mixed overdose of multiple lipid-soluble drugs. He did not respond to maximal medical therapy but improved after the introduction of Intralipid. The possible mechanisms of action and potential adverse consequences of using Intralipid in this context are reviewed.
Noradrenaline versus Dopamine in the Treatment of Circulatory Shock
Authors: Ebrahim Hozefa , Torlinski Tomasz
Published: December 2014

There is no difference in the rate of death between individuals randomised to receive dopamine or noradrenaline as first-line treatment of circulatory shock. However, the use of dopamine was associated with a greater incidence of adverse events, especially in those patients with cardiogenic shock.
Vasopressin in Septic Shock
Authors: Gordon Anthony
Published: December 2014

In recent years there has been growing interest in the use of vasopressin as an adjunctive vasopressor in septic shock. This review article aims to summarise the rationale for its use, review the evidence of its effects in clinical studies and consider future areas of research.
Levosimendan in the Treatment of Acute Heart Failure, Cardiogenic and Septic Shock: A Critical Review
Authors: Mathieu Steve , Craig Gordon
Published: December 2014

Levosimendan is a drug which increases the sensitivity of the heart to calcium and which opens potassium channels, resulting in inodilation. Clinical trial data from patients suffering from heart failure have demonstrated that it improves haemodynamics without increasing intra-cellular calcium or oxygen consumption. However, there is no consistent evidence of mortality reduction. This narrative review summarises the key trials of its use in acute heart failure, acute coronary syndrome, cardiogenic shock and septic shock.
Statin Therapy Associated with Fatal Rhabdomyolysis
Authors: Frohlich Stephen , Ryan Tom , Fagan Carl
Published: December 2014

A 54-year-old man was admitted to the intensive care unit six weeks after a myocardial infarction suffering from metabolic derangement secondary to rhabdomyolysis. There was no obvious precipitant for his condition, though he had recently had his atorvastatin dose increased from 10 mg to 80 mg and a number of new medications commenced. Extensive investigations failed to identify other causes of rhabdomyolysis and it was concluded that his condition related to a combination of statin therapy with other medications, namely the anti-staphylococcal agent fucidic acid. Despite discontinuation of his statin therapy, rhabdomyolysis persisted and the patient died from sepsis related to a prolonged ICU stay. This case highlights the potential risks of statin therapy, particularly in the critically ill patient population, where there may be significant interactions between statins and other co-prescribed medications. Such interactions can lead to impaired statin metabolism, potentially increasing the risks of rhabdomyolysis and other serious side effects.
The Mental Capacity Act 2005 and its Impact in Critical Care
Authors: Chatfield Doris A , Menon David K
Published: December 2014

The Mental Capacity Act (MCA) 2005, covering England and Wales, provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they may lack capacity in the future. The Act came into force during 2007 and applies to everyone ‘habitually resident or present in England and Wales’. Essentially it has translated in to law what has always deemed to be best practice. However it is vital that all healthcare professionals be familiar with the MCA and its accompanying Code of Practice. This article is aimed at those working in the critical care environment and will help to clarify some of the issues raised by the MCA.
The Knowledge of Medical Students and Newly Qualified Doctors concerning the Specialty of Intensive Care Medicine
Authors: Kelly Daniel
Published: December 2014

Current evidence suggests that around the transition from undergraduate to postgraduate training, deficiencies exist in doctors' knowledge of acute care. This study assessed Foundation Year 1 (FY1) doctors and medical students in intensive care/acute medicine with respect to their understanding of ICU practice and identifying critically ill patients. A qualitative questionnaire was formulated focusing on several targeted areas including training experience, broader ICU knowledge, formal assessment of ICU medicine and critically ill patients encountered outside the ICU. After successfully piloting the study, ethics approval was granted. In February 2010, the questionnaires were distributed to 50 final-year medical students at Brighton and Sussex Medical School and 50 FY1 doctors working at Worthing Hospital or the Royal Sussex County Hospital. One hundred percent of participants completed the questionnaires; 12.5% of medical students knew about the Surviving Sepsis Campaign compared to 62% FY1s (p<0.05). Non-significant trends were evident when choosing three most useful observations for identifying sick patients. The study concluded medical students lack knowledge regarding assessment and monitoring of critically ill patients. Undergraduate training and ICU exposure did not differ between groups, however differences existed in understanding of ICU practice. There was a relative paucity in understanding from final year students regarding the Surviving Sepsis Campaign compared to FY1 doctors, which highlights the need for further improvement.
Multimodal Cerebral Monitoring in Traumatic Brain Injury
Authors: Vidgeon Steven D , Strong Anthony J
Published: December 2014

Traumatic brain injury presents a significant impact on patients in terms of morbidity and mortality. Pathology is heterogeneous and is often associated with secondary deterioration. This paper reviews both clinical and research modes of monitoring to detect deterioration and compares what is available to the ideal. Intracranial pressure measurement, jugular venous oxygen saturation, microdialysis and cerebral oxygen monitoring are among the variables described and future research-based modalities are explored.
Rescue of Acute Refractory Hypercapnia and Acidosis Secondary to Life-Threatening Asthma with Extracorporeal Carbon Dioxide Removal (ECCO2R)
Authors: Lobaz Steven , Carey Michelle
Published: December 2014

We report a case of life-threatening asthma associated with profound hypercapnia and acidosis that was refractory to conventional medical therapy but was managed successfully using an extracorporeal carbon dioxide removal (ECCO2R) device (NovaLung iLA®). In the UK, ECCO2R is still not widely available, with few intensivists and anaesthetists having experience of its use in routine intensive care unit practice. Extracorporeal CO2 removal may have a role in the management of acute life-threatening asthma and in preventing patient death and improving overall outcomes.
Post-Traumatic Invasive Mucormycosis
Authors: Marchetti Andrew , Jayachandran Anuradha , Guha Arpan
Published: December 2014

A 60-year-old man involved in a high-speed collision with a hay wagon was admitted with multiple trauma. He developed life-threatening invasive musculo-cutaneous zygomycosis caused by Rhizopus species, which is found in soil from cultivated land and woodland. A high index of suspicion given the nature of the injury, aggressive surgical debridement and appropriate anti-fungal therapy prevented a fatal outcome.
Nebulised Heparin is Associated with Fewer Days of Mechanical Ventilation in Critically Ill Patients
Authors: Gross Jamie
Published: December 2014

This small randomised controlled trial (RCT) of ventilated patients failed to demonstrate an improvement in PaO2/FiO2 with the use of regular nebulised heparin. However, nebulised heparin was associated with an increase in ventilator-free days.

Level of evidence: 1+ (RCT with a low risk of bias)
Intensive Care Admission Triage during a Pandemic: A Survey of the Acceptability of Triage Tools
Authors: Ashton-Cleary David T , Tillyard Andrew RJ , Freeman Nicola VE
Published: December 2014

We conducted a survey of the UK Intensive Care Society regarding physician opinion of national guidance on ICU triage during a viral pandemic. Respondents graded agreement for seventeen triage criteria, ten from the Department of Health. We determined whether respondents accepted the whole tool on the basis of proportion of criteria agreed with. A modified tool was devised and acceptability compared. Five hundred and fifty questionnaires were returned (33.1% from senior physicians). Approximately half of senior physicians (49.5%) and 44.4% of other respondents found the tool acceptable. This improved to 68.7% and 59.2% for the modified tool. Chi-square analysis revealed no statistically significant difference between the opinions of senior physicians and other respondents (p=0.850 for the original tool, p=0.593 for the modified tool). A small change to the government guidelines produced a tool with improved acceptability among ICU physicians.
Drotrecogin Alfa (Activated) in Severe Sepsis: A Single-Centre Series of 110 Patients
Authors: Pathmanathan Nimalan , Fletcher Stephen J
Published: December 2014

We present our experience with drotrecogin alfa (activated) in 110 patients. Data were collected on diagnosis, acuity, complications and outcomes. Crude ICU and hospital mortality was high at 47.3 and 55.5% respectively (hospital SMR = 1.02). Our patients appeared to be sicker than in other published series (mean number of organ failures = 4). The rate of serious bleeding events was comparable to the PROWESS trial. Usage fell during the study period from 37 patients in 2005 to 14 patients in 2008 and is likely to reflect uncertainty over the risk-benefit profile.
Mental Capacity Act 2005 and Research
Authors: Chatfield Doris A , Menon David K
Published: December 2014

This article is the second of two describing the impact of the Mental Capacity Act on the practice of intensive care medicine in the UK. This article concentrates on the impact on clinical research. Intrusive research in incapacitated patients that does not involve trials of medicines or non-identifiable data is covered by the Act. Research must have Ethics Committee approval and must have some chance of benefiting the research subject or provide information about the disease without causing risk to the patient or being unduly invasive or restricting the patient's freedom. It is the responsibility of those engaged in clinical research to be aware of the requirements of the Act and to interpret and implement it appropriately.
CT Scanning in Polytrauma
Authors: Davies Ed Denison
Published: December 2014

The use of whole body CT significantly increased the probability of survival in patients with blunt polytrauma.

Level of evidence: B, 3+ (large retrospective multi-centre study)
Use of Dexmedetomidine as a Sedative and Analgesic Agent in Critically Ill Adult Patients
Authors: Clark Sam , Ezra Martyn
Published: December 2014

A meta-analysis of randomised controlled trials comparing dexmedetomidine to control sedation showed weak evidence that dexmedetomidine might reduce length of intensive care unit (ICU) stay in certain critically ill patients, but the risk of bradycardia was significantly higher when using both a loading dose and high maintenance doses (>0.7 μg/kg/h). There was, however, a significant heterogeneity between trials reported.

Level of evidence: 1++ (Meta-analysis with a very low risk of bias)
A Randomised Trial on the Treatment of Refractory Status Epilepticus
Authors: Jenkinson Emma , Tulloch Laura , Tunnicliffe William
Published: December 2014

This study failed to show a significant difference in outcome between those receiving propofol versus barbiturates in the treatment of refractory status epilepticus, except in duration of mechanical ventilation. However, due to a failure to recruit sufficient numbers of patients, the trial was significantly underpowered and we recommend caution when drawing any conclusions from the data.

Level of evidence: 1− (RCT with a high risk of bias)
Specialty Training Applications – is there a Recipe that Works for All?
Authors: Farrow Susan
Published: December 2014

Susan Farrow has five years experience of working in the private sector with Oxbridge Applications, assisting prospective medical students in their application forms. She has a background in personal tutoring, writing personal statements and providing interview practice. Please note that the assistance provided is guidance and recommendation and that ultimately a student's application form must always be their own work. Nevertheless there are strategies available which may ease the application process and alleviate anxieties associated with this experience for applicants.
Extracorporeal Membrane Oxygenation: Coming to an ICU near you
Authors: Hung Matthew , Vuylsteke Alain , Valchanov Kamen
Published: December 2014

Extra-corporeal membrane oxygenation has come of age after publication of the CESAR trial and the experience of its use during the 2009 H1N1 influenza pandemic, showing its increasing benefit for the treatment of hypoxaemic respiratory failure and combined cardiovascular and respiratory failure, including post-cardiac arrest. The article reviews the evidence for this technology and its indications, modes, methods, complications and recent advances. The authors suggest that ECMO will be used increasingly, even in non-cardiac specialist centres.
Gout Presenting as Severe Sepsis and Septic Shock
Authors: Cheung Mary , Bion Julian , Kerry Robbie
Published: December 2014

This is a case of a 49-year-old patient presenting with signs consistent with sepsis, which proved to be secondary to acute gout.
Low-Dose Hydrocortisone in Patients with Cirrhosis and Septic Shock
Authors: Keegan James , Bromilow James
Published: December 2014

Low-dose hydrocortisone in septic patients with cirrhosis does not improve outcome and may lead to harm.

Level of evidence: 1B
Use of a Microbiology Database to Analyse Changes in Resistance Patterns in the ICU
Authors: Brown Jules M , Nickols Gemma , Garcia Miguel
Published: December 2014

We combined our ICNARC dataset with a microbiology database in a mixed general and neurosurgical intensive care unit (ICU). We identified 1,097 positive tracheal aspirate cultures in 2,525 consecutive adult patients admitted over a three-year period. The database enabled us to track changes in tracheal aspirate flora and antibiotic resistance patterns following the introduction of a hospital-wide restrictive antibiotic policy targeted at Clostridium difficile infection (CDI) reduction. The pattern of organism types was unchanged although meticillin resistance in Staphylococcus aureus decreased from 33% to 17% (p=0.014). Sensitivity of tracheal aspirate cultures to empirical antibiotics increased from 67% to 86% in the first five days after hospital admission and from 53% to 81% in the subsequent five days. A combined microbiology/ICU database allowed resistance patterns to be identified within our unit. We believe this should be developed nationally both for research and for real time targeting of empiric antibiotic therapy.
Intensive Care Unit Acquired Weakness: Measuring Recovery from Critical Illness
Authors: Corner Evelyn J
Published: December 2014

Critical illness can lead to muscle wasting, functional decline and long-term disability. This is well described subjectively in the literature; however, to date, objective measures have proved elusive. This narrative review aims to explore the objective measurement tools available to assess intensive care unit-acquired weakness, to review the psychometric properties of these tools and to show current practice and the obstacles we face in the development of new measurement scales.
Decompressive Craniectomy in Acute Brain Injury – Lifting the lid on Neurosurgical Practice
Authors: Hempenstall Jonathan , Sadek Ahmed-Ramadan , Eynon C Andrew
Published: December 2014

Decompressive craniectomy (DC) is an effective method of controlling rising intracranial pressure (ICP) refractory to medical treatment in a range of conditions: traumatic brain injury in both adults and children, malignant middle cerebral artery infarction and following subarachnoid haemorrhage. Herein, we describe its indications, prognosis, current operative methods and postoperative management.
Extracorporeal Carbon Dioxide Removal (ECCO2R) in Respiratory Failure: An Overview, and where Next?
Authors: Baker Andrew , Richardson Dominic , Craig Gordon
Published: December 2014

Extracorporeal carbon dioxide removal (ECCO2R) is used to facilitate protective ventilation strategies and to treat severe hypercapnic acidosis that is refractory to mechanical ventilation. There is an increasing amount of interest in the use of ECCO2R but there are no recommendations for its use that take the most recent evidence into account. In 2008, the National Institute of Health and Clinical Excellence (NICE) published guidelines on ‘Arteriovenous Extracorporeal Membrane Carbon Dioxide Removal.’1 However, since that time there have been a number of studies in the area and some significant technological advances including the introduction of commercially available VV-ECCO2R systems. The aim of this article is to provide an overview of ECCO2R, review the literature relating to its use and discuss its future role in the intensive care setting.