Journal of the Intensive Care Society最新文献

Background: The intensive care unit (ICU) may be described as a 'deliriogenic' environment. Critically ill patients diagnosed with delirium are at increased risk of long-term cognitive impairment and hospital mortality. Best practice guidelines recommend early mobilisation interventions to manage and prevent delirium in ICUs. However, evidence evaluating the impact and role of early mobilisation upon delirium in ICUs from the patient perspective is lacking. The aim of this study was to understand the experience of early mobilisation from the perspective of patients diagnosed with delirium in the ICU.

Methods: This qualitative study adopted a phenomenological approach. One focus group including three participants and seven semi-structured one-to-one interviews were conducted with patients previously diagnosed with delirium in the ICU. Data were analysed using Braun and Clarke's thematic analysis. Face validity of findings was reviewed by a public representative on the research team.

Results: Six main themes were identified: (1). The vivid reality and isolation of delirium, (2). Loss of control, (3). Delirium as a barrier to mobilisation, (4). The role of different methods of mobilisation (5). Facilitating mobilisation and recovery of self, and (6). Grounded back into reality.

Conclusion: This qualitative study demonstrated the impact and role of mobilisation interventions going beyond the patients' physical recovery from critical illness. These findings support current best practice recommendations for the implementation of early mobilisation interventions in ICUs.

Each year, around 30,000 intercostal chest drains (ICDs) are inserted in the UK, with complications like displacement being a common concern. Various fixation techniques have been proposed to secure ICDs, but there is no consensus on a gold standard. A scoping review was conducted to identify publications describing ICD fixation methods and frequency with which they become dislodged. Three databases were reviewed: MEDLINE from 1946 to 17th October 2024 through the Ovid^® website portal, PubMed^®, and the Cochrane Central Register of Controlled Trials (CENTRAL). Appropriate search terms and synonyms were applied with Boolean operators and from 5275 identified records 63 were included for review. Nine ICD fixation principles were identified to classify fixation methods: kinking; Poisson-effect ("Roman Sandal"); suture "through" the tube; tube fixation points (cuffs or wings); friction/adhesion (from ties or dressings); external coiling/locking/flattening; internal balloons; internal coiling (pigtails); subcutaneous tunnelling. Many fixation methods combined more than one principle. Although no definitive conclusions on the best fixation method can be drawn from this review, trends suggest that incorporating sutures or using combined techniques, such as sutures paired with dressings, cable ties or balloon catheters, may enhance ICD security. In laboratory conditions, the highest pull force was associated with the modified Jo'berg knot. Further robust studies are needed to compare the effectiveness of different fixation methods superior in terms of displacement rate, but also taking into account pain, skin integrity, wound leakage/infection, or ease of use.

Background: Dose Error Reduction Software (DERS) are downloaded onto Smart Pumps with minimum and maximum infusion rate settings to reduce the risk of medication errors when administering intravenous medicines. There are no current national standards for the application of this technology on Adult Intensive Care Units (ICU), and clinical application and governance of this technology is currently unknown.

Method: A multicentre, cross-sectional survey was conducted using a self-administered questionnaire to explore practical aspects of Smart Pump containing DERS use, such as whether a DERS library was present, how it was managed, how propofol was administered, what kind of error reporting processes were in place, as well as nursing qualifications and competencies on ICUs in England.

Results: A response rate of 50.7% (136/268 responses) ICUs units in England was achieved and indicated that 63.2% (86/136 responses) of responding units had a Smart Pump containing a DERS library. Three administration strategies were used, mg/kg/h, mL/h and 'Other' (which most responses stated as mg/h) for propofol for continuous sedation in ICU Smart Pump containing DERS libraries. In 68.6% (49/86 responses) of ICUs, DERS use and DERS error rates are not reported through local operational and governance structures. DERS use was significantly associated with units having a Clinical Nurse Educator with a postgraduate education certificate (p = 0.005).

Conclusions: There are no standardised DERS settings for the anaesthetic agent propofol and inconsistent approaches to Smart Pump containing DERS governance oversight across ICUs in England. Further research is required to understand the clinical significance of identified variability.

Background: With 10-years' worth of growth in the use of LUS by physiotherapists within the U.K., this survey explores their training, implementation and clinical practice experiences.

Methods: A cross-sectional survey was delivered to U.K. Physiotherapists accredited in LUS. The 50-question survey was administered via JISC online and was open for 4-weeks in January 2025. Closed questions were presented descriptively; open questions underwent inductive conceptual content analysis and descriptive coding.

Results: Of the 223 invitations, 168 surveys were returned (75% response rate). Responses were highest from four U.K. regions which correlated with a higher number of regional mentors. Most respondents were in band 7 static roles, accredited via FUSIC^® and worked on the ICU with respiratory or surgical patients. The primary indication to perform a LUS was an increase in the fraction of inspired oxygen, average scanning frequency was 1-2 per week and common pathological findings were consolidation (pneumonia and atelectasis) plus pleural effusion (transudative and exudative). The most common negative factors experienced overall were limited time to scan and access to an US machine. Additional negative factors were limited access to a mentor during training, limited support from other professions during implementation, limited access to an appropriate patient population to scan during clinical practice.

Conclusion: This is the largest survey to investigate the experiences of physiotherapists using lung ultrasound in the U.K. and provides important insights during training, implementation and clinical use. The specific details of these findings will support both current and future LUS users to plan and develop robust physiotherapy LUS service.

Obtaining patient feedback for personal reflection, development and GMC revalidation as an ICU consultant is complex. Various options for alternative evidence for revalidation have been suggested by FICM guidance. Communication with families at a time of crisis is core to the role of an ICU consultant and is something we should endeavour to seek feedback on to enable reflection and personal development, and which may also be useful evidence for GMC revalidation. In this article we propose a method for obtaining third party feedback on key communication events which we have demonstrated to be workable and useful.

This is the opposing view editorial to the one produced by Dr. Crossingham and argues that CCU doctors should not be discharging patients home without appropriate investment in training and support.

Background: Critically ill patients with lower respiratory tract infections often fail to achieve therapeutic beta-lactam antibiotic concentrations, despite standard dosing. Therapeutic drug monitoring (TDM) may improve attaining drug exposure, but delayed turnaround times limit its clinical impact. The objective of this study was to evaluate the feasibility of delivering real-time beta-lactam TDM results within two dosing intervals.

Methods: We conducted a single-centre prospective cohort feasibility study in two ICUs in Manchester, UK. Critically ill adult patients receiving piperacillin/tazobactam or meropenem for suspected or confirmed lower respiratory infection were enrolled. Blood samples were collected for analysis and drug quantification, with the primary outcome being the proportion of TDM results returned within two dosing intervals. Secondary outcomes included detailed time-to-result, clinical and microbiological outcomes. TDM results were not released to clinical teams.

Results: We recruited 30 participants, of whom 20 (67%) had TDM results available within two dosing intervals. The median time from blood sampling to TDM result was 10.9 h, with a median time from antimicrobial initiation to result of 25.4 h. At 28 days, 70% of participants were alive, with a median (IQR) ICU and hospital length of stay of 7 (5-25) and 17 (10-27) days, respectively. Resistant pathogen strains were isolated in 4/21 (19%) participants.

Discussion: Recruitment of critically ill participants into a time-sensitive trial of TDM is feasible. Timely feedback of beta-lactam TDM results to clinicians is achievable, however, barriers to streamlined around-the-clock implementation remain. Future clinical trials of beta-lactam TDM should factor turnaround times into study design.

Registration: NCT05971979.