Journal of the Intensive Care Society最新文献

Pleural procedures are fundamental skills for intensive care specialists. While competency in these procedures is not explicitly mandated within the Intensive Care Medicine (ICM) curriculum, achieving proficiency remains a vital goal for ICM trainees. Anecdotal evidence suggests that training in this area is often perceived as inadequate, with considerable variability in practice across intensive care units (ICUs). We conducted the first survey of ICM trainees in the UK to evaluate routine practices, formal training, accreditation, and perceived competence. The findings revealed significant gaps in training. Confidence levels in performing chest drain varied widely, and a notable deficiency in thoracic ultrasonography (US) training was identified. Additionally, it was observed that many ICUs frequently rely on non-ICM specialists to perform pleural procedures. These results underscore critical areas for improvement within ICM training. The authors advocate for enhanced education, structured training programmes, and increased support to address these deficiencies. This will ensure that trainees and future consultants are adequately equipped to perform pleural procedures with confidence and competence.

Background: Between April 2022 and March 2023, 43.8% (88,259) patients admitted to Intensive Care Units (ICU) in the United Kingdom (UK) required breathing support through a ventilator, the majority require sedation. Unfortunately, mechanical ventilation is associated with high mortality and morbidity, and sedative agents currently used have significant side effects including hypotension and delirium. They are also implicated in long-term psychological sequelae such as major depression and posttraumatic stress disorder. Ketamine has been utilised in anaesthesia for over 50 years and has an excellent safety profile. The diverse properties of ketamine are the focus of much research currently, including its properties as a potent antidepressant. Ketamine has not been fully investigated in the context of ICU, and there are gaps in the evidence that warrant further investigation through a large randomised controlled trial. Preparatory work for such a study includes refining study designs, identifying key clinical and patient centred outcomes and exploring barriers to implementation, which is the focus of this work.

Methods: SHOCK-ICU is a single centre, non-randomised, feasibility study assessing the feasibility of continuous ketamine infusions for the provision of sedation for 30 patients undergoing mechanical ventilation on the ICU.Data will be collected at baseline, daily until >48 h without mechanical ventilation, ICU discharge, and 90-days from enrolment. Data collection will include trial aspects such as expected recruitment, refusal, and follow-up rates, ability to collect data, and exploratory assessment of clinical efficacy markers.

Primary outcome: The primary outcome is study feasibility; this will be assessed using pre-defined progression criteria that will aid design of future ketamine sedation studies.

The use of corticosteroids in severe community-acquired pneumonia (sCAP) management is a contentious issue with current practices of United Kingdom (UK) intensivists largely unknown. To investigate this, we surveyed UK intensive care clinicians from 20 September 2024 to 19 December 2024, collecting 160 responses from 115 intensive care units (response rate 48.3%). 56.1% of responders use corticosteroids in the treatment of sCAP. There were large variabilities in practice. Hydrocortisone started within 24 h of admission 50 mg four times a day for 4-5 days was the most reported regime. The variation in practice coupled with relative equipoise requires further evaluation and guidance.

Background: Spinal cord injury (SCI) is a devastating condition with a high burden of morbidity and mortality. National guidelines state that patients should not receive enteral feeding for 48 hours after inury, which may be detrimental if a patient experiences a hypercatabolic response to polytrauma. We conducted a systematic review of the benefits and harms of delayed enteral feeding in this population.

Methods: We searched MEDLINE, EMBASE and Cochrane CENTRAL for studies which had a time parameter as part of their evaluation of feeding in the acute phase of spinal cord injury in a critical care setting. Required outcomes for inclusion were neurological improvement, neurological complications, time spent in an ICU, time to ICU discharge, incidence of secondary complications, other adverse effects and mortality. Risk of bias was assessed with the Downs and Black checklist.

Results: Four studies met the inclusion criteria. There was no high-quality evidence of worsened outcomes with earlier feeding compared to delayed enteral feeding. One study demonstrated that patients fed before 24 h in conjunction with a broader bundle of care had improved neurological outcomes compared to previous non-standardised practice. There was no evidence of difference in frequency of infections or mortality in early or late feeding groups.

Conclusions: We find no clear evidence of increased risk of harm from earlier enteral feeding strategies, nor clear evidence of benefit of earlier feeding as an isolated intervention.

Objective: This retrospective observational study conducted in a general ICU aimed to evaluate the hemodynamic impact of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration.

Design: The study was designed as a retrospective observational study in a general ICU setting.

Setting: The study was conducted in a general intensive care unit (ICU).

Patients: Data from 498 patients receiving IV paracetamol in various clinical contexts were analyzed.

Interventions: Patients received IV paracetamol for analgesia and fever reduction as part of their clinical care.

Measurements and main results: The study analyzed the hemodynamic effects of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration. A significant decrease in mean systolic and diastolic blood pressure values was observed across different patient subgroups, notably 45-60 min post-infusion. An increase in noradrenaline dosage and a decrease in urine output indicated a decline in end-organ perfusion following IV paracetamol administration. Multivariate analysis identified associations between clinical factors (such as general anesthesia and cardiac conditions) and changes in blood pressure.

Conclusions: While IV paracetamol remains a valuable therapeutic option for pain and fever management, especially in hypertensive patients with specific conditions like traumatic brain injury and cerebral vascular accident, careful monitoring, and individualized dosing strategies are recommended in critically ill patients to maintain hemodynamic stability and optimize clinical outcomes. These findings contribute to enhancing our understanding of IV paracetamol hemodynamic effects and inform evidence-based practices for its use in ICU settings.

Background: Critical care nurses experiencing high levels of emotional exhaustion (EE). However, limited studies explored the association between generational differences and nurses' perceived EE. The objectives of the current study were to: (1) assess generational differences in EE among critical care nurses and (2) examine the link between nurses' EE and the generational differences, occupational stress, structural empowerment, and nurses' perceived work environment.

Methods: A proportional stratified clustered sampling technique was utilized. The hospitals were stratified according to their location. Data were collected from nurses working at 19 hospitals in Oman. The emotional exhaustion sub-scale of the Maslach Burnout Inventory was used to assess the level of EE among nurses working in critical care units.

Results: A total of 714 staff nurses participated. The majority (78%) were from generation Y and 22% were from generation X. Regression analysis showed that generation Y critical care nurses experienced higher EE levels than generation X nurses. Increased psychological stress among nurses was associated with increased EE. Higher levels of access to support, resources, and information, as well as supportive managerial leadership and sufficient staffing and resources, were associated with significant reductions in EE.

Conclusion: To reduce job burnout among critical care nurses, healthcare leaders are required to ensure adequate staffing, provide managerial support, and monitor stress and EE levels frequently, particularly among generation Y nurses.

Background: We assessed the healthcare and economic burden of sepsis in adult hospitalised patients in Wales, UK.

Methods: We analysed hospital admissions to all acute hospitals in Wales via the Secure Anonymised Information Linkage Databank. We included all adult patients, 2006-2018, with an inpatient admission including one or more explicit sepsis codes.

Results: 38,564 patients had at least one admission for sepsis between 2006 and 2018. Most persons (86.7%) had just one admission. 3398 patients (8.4%) were admitted to ICU. The number of admissions increased yearly over the study period from 1548 in 2006 to 8708 in 2018. The largest annual increase (141.7% compared to the previous year) occurred in 2017. Admission numbers increased disproportionately amongst patients with high levels of comorbidities, but changes were consistent across all age groups, areas of deprivation and ICU admissions. Estimated inpatient sepsis costs were £340.34 million in total during the study period. The average cost per hospital spell was £7270. Patients readmitted to the hospital for sepsis amassed estimated treatment costs of over £72 million during the study period. Out of the 38,564 persons, 21,275 (55.2%) died within 3 years of their first admission. Inpatient mortality halved from 40.5% to 19.5%, and there was a trend towards reduced mortality at 6 months, 1 and 3 years post hospital discharge.

Conclusion: Sepsis related hospital admissions are increasing over time and still likely to be underreported. Although mortality appears to have fallen, prolonged hospitalisation and readmissions place a significant burden on healthcare system resources and costs.

Background: POCUS is increasingly in utility and application across a variety of specialities. Although several professional societies, including the European Society of Intensive Care Medicine (ESICM) have recommended focussed Neurological ultrasound be a core competency, recommendations on how best to achieve this competency are lacking.

Aim: The purpose of this systematic review was to assess what best-practice and evidence-based recommendations are available to achieve competency in Neurological Point-of-care ultrasound (NeuroPOCUS).

Methods: We undertook a structured systematic review of publications and studies on the training of NeuroPOCUS for intensive care.

Results: Our search strategy yielded a total of 4965 publications, reduced to 3551 following de-duplication. Despite this, only 28 publications were relevant following review of title and abstract and only 12 of these on full-text review. We identified three prospective studies, four consensus statements and five publications as posters and published abstracts. Structured analysis of these revealed minimal evidence-based teaching recommendations, and significant variability in teaching method.

Conclusion: Compared to other modalities of POCUS (e.g. Cardiac and Lung), NeuroPOCUS lags behind with regards to utilisation and training in the general intensive care setting. Further work is needed to establish how this technique can be effectively taught and assessed for clinical application.

Introduction: Non-medical consultant level roles have been in existence for over 30 years, however the number of allied health professionals (AHPs) working at this level, particularly in critical care, remains relatively small. National guidance highlights the importance of clinicians in these roles to work across the four pillars of practice. However, little research exists regarding the roles undertaken by these consultant-level practitioners, the contributions made to service delivery and their perceived impact on patient and service outcomes. Based on this, the aim of this project was to explore the perceived impact of consultant-level AHPs working within critical care.

Methods: Qualitative methodology was used involving a combination of interviews and focus groups. Purposeful sampling was used to recruit AHPs in consultant-level positions within critical care. Senior medical and nursing staff were then recruited via the AHPs. Data were analysed thematically using the Braun and Clarke methodology.

Results: Five consultant-level AHPs were recruited to participate in interviews, with a further 7 participants from senior medical and nursing roles participating in one of two focus groups. The AHPs had been in a consultant-level role for an average of 3.2 years, with all participants reporting over 15 years' experience within critical care. Four core themes were generated from 105 unique codes and 13 subthemes. Personal characteristics were apparent across all themes and therefore was included as a central element. The core themes were (1) scope; (2) status; (3) supportive leadership and (4) impact.

Discussion: Through four core themes, this study has highlighted the roles undertaken by consultant-level AHPs working in critical care, their perceived impact on patient and service outcomes, and their contribution to local, regional and national workstreams. Where these roles exist, they appear to be well received by senior medical and nursing staff, reporting the benefits of highly experienced members of clinical staff to improve service delivery, patient outcomes and contribute to strategic planning.

Around 13% of patients admitted to critical care in Europe die in the Intensive Care Unit (ICU). In the United Kingdom, 15%-20% of patients admitted to critical care do not survive to discharge. Of those that die in ICU, 80% do so following an active decision to withdraw life-sustaining therapy (WLST). With the increasingly aged and co-morbid critical care population entering the ICU, there is an ongoing need for timely, considered discussions both when initiating life sustaining therapies, and also for effective, sensitive communication and management when it comes to withdrawing. In the case of WLST, very little data exists reflecting the proportion of scenarios involving an 'awake' patient with capacity to take part in this decision. It is, however, generally thought to be a small proportion. Most intensivists will therefore have less experience in this process, which perhaps is more representative of the work of our palliative care colleagues. We aim to discuss the most common scenarios in which WLST may occur in the awake and capacitous patient in critical care, the challenges to providing this, and some practical advice on how to perform it well, including the benefits of early interdisciplinary collaboration alongside palliative care.