Journal of the Intensive Care Society最新文献

Background: The ICU Liberation Bundle was developed to improve outcomes for patients admitted to critical care. Despite a lack of Bundle adoption in the UK, the individual evidence-based practices (EBPs) within the bundle are defined as standards of care by the UK Intensive Care Society. There are limited data on the delivery of these EBPs.

Objective: To evaluate current delivery of the EBPs of the ICU Liberation bundle in a sample of hospitals in the UK National Health Service (NHS) presenting delivery of EBP's between hospitals, their stability of delivery across multiple weeks and in comparison to US hospitals in the original ICU Liberation Bundle study.

Methods: Multi-centre service evaluation, using modified definitions of compliance from the ICU Liberation Bundle study. We sampled six representative units from across the UK; data collection totalled 1116 patient days. Data were analysed using descriptive statistics.

Results: Across all six units, patients received a median of 42.9% (IQR 40%-60%) of all possible bundle EBPs. Unit bundle proportional compliance (number of components completed/eligible number of components) ranged from 40.0% (IQR 28.6%-50.0%) to 71.4% (IQR 57.1%-80.0%). Units completed spontaneous awakening trials most regularly in 80.1% of eligible patients (149/186). Delirium assessments were the least adhered to EBP with only 32.2% (359/1116) of patients receiving at least two validated delirium assessments per day. Full bundle compliance was lower in the UK cohort in comparison to the original trial (4% vs 8%).

Discussion: We identified substantial variation in the delivery of seven evidence-based practices that are considered standards of care in the UK. Variation existed between hospitals and within each hospital over time. These data begin to describe the current state of EBP adherence in a selection of critical care units.

There are instances where hospitals may experience a relative shortage of oxygen, for example, future pandemics, natural disasters or wartime. We developed a modification to a domiciliary ventilator that captures oxygen normally vented during expiration into the atmosphere, delivering it to the patient. The modification significantly increases PaO₂ in mechanically ventilated patients at their baseline FiO₂ and baseline FiO₂ +1, +2 and +3 L/min compared to no modification. The modification reduces walled oxygen consumption by median (IQR) -1.0 (-1.25 to -1.00) L/min whilst maintaining PaO₂. This modification may be a valuable in circumstances where there is a relative shortage of oxygen.

Background: Mechanical ventilation is a common and often lifesaving intervention that is utilised in intensive care. However, the practices can vary between centres. Through this national survey we aim to gain more information about different strategies adopted across the UK.

Methods: All adult intensive care units in the UK were approached to participate. The questionnaire was developed with an electronic survey engine and conducted between 09/11/2023 and 01/04/2024 (Survey Monkey^®). The survey included questions on ventilator modes, settings, protocols/pathways, rescue strategies, immediate post-extubation period and follow-up.

Results: There were 196 responses from 104 hospitals. The most widely adopted start-up ventilation mode was pressure-regulated volume-controlled mode. For acute hypoxaemic respiratory failure (AHRF), most of respondents reported full (39.8%) or partial compliance (58.1%) with the ARDSnet protocol, with PEEP settings being the commonest deviation. Prone positioning (99.0%), followed by recruitment manoeuvres (91.3%) were commonly used rescue measures during AHRF. APRV (55.7%), inhaled (51.3%) and systemic pulmonary vasodilators (44.1%) were also commonly used. Conservative oxygen targets (SaO₂ of 88%-92%) were commonly adopted (70.6%). As a care bundle, intermittent ETT cuff pressure monitoring was more common (65.5%) than continuous cuff pressure monitoring (20.0%). Propofol and alfentanil were the most common initial sedative and analgesia (99.5% and 56.9%) respectively. Routine volatile anaesthetic use was rare.

Conclusions: Our survey has shown significant variation of practice in common but crucial elements of management of patients receiving mechanical ventilation. We hope the results in our survey highlight potential future areas of research.

Collaborators: South-coast Peri-operative Audit and Research Collaborative (SPARC)Severn Trainee Anaesthetic and Critical Care Research group (STAR)Collaborative research in Anaesthesia in the Northeast (CRANE).

Background: Fluid therapy is universally administered in the management of patients with sepsis, however excessive cumulative fluid balance has been shown to result in worse outcomes. Hyperoncotic albumin results in both lower fluid volumes and early cumulative fluid balance, and may reduce short-term mortality in patients with septic shock.

Methods: In this single centre, open label, feasibility trial; patients with early septic shock will be randomly allocated either 20% albumin for resuscitation and daily supplementation, versus buffered crystalloids alone for all fluid therapy. The intervention period will last 7 days, with follow up points at ICU and hospital discharge, and 90 days after randomisation.

Objectives: Primary outcome measures including recruitment rate, intervention adherence, data completeness and safety will constitute objective evidence of feasibility, according to pre-specified thresholds. Secondary outcomes will include mortality and healthcare utilisation at 90 days, alongside other physiological and patient centred outcomes to inform the design of a future effectiveness trial.

Conclusion: This study will rigorously test the feasibility of conducting a future trial to test both the clinical and cost-effectiveness of hyperoncotic albumin in patients with early septic shock.

Viscoelastic tests (VETs) have transformed assessment of haemostasis and transfusion practices in trauma, cardiac and liver transplantation centres. Impaired haemostasis is a common problem on the general intensive care unit (ICU), but routine use of VETs is rare. We have accordingly reviewed the evidence to determine whether there is evidence to support the use of VETs as a standard point of care test on all ICUs in assessing and managing patients. The benefits of using VETs in the management of major haemorrhage, namely faster identification of a coagulopathy, in particular early detection of fibrinolysis, and reduced transfusion requirements for blood products have been seen in the general ICU. Validation of treatments algorithms is now required to standardise practice. There is also emerging evidence to support the use of VETs to guide urgent treatment decisions in patients with a coagulopathy or in patients taking anti-coagulants or anti-platelet therapies. We recommend that departments independently review the feasibility of setting up a viscoelastic point of care service which considers the applicability to their patient cohort, the financial cost and the personnel required.

The diagnosis of death by neurological criteria (DNC) requires the exclusion of any clinical effect attributable to xenobiotics. We undertook a retrospective analysis of enquiries to the National Poisons Information Service (NPIS) relating to DNC over a 10-year period. Enquiries were categorised as toxicological, where exposure to a non-therapeutically administered xenobiotic was implicated in the clinical presentation and non-toxicological where exposure to the xenobiotic was not the primary cause of the clinical state. The frequency of enquiry to the NPIS regarding xenobiotics and DNC demonstrates that it remains a valuable source of expert advice.

More patients are discharged directly to home (DDH) after intensive care admission. This single-centre study compared admission characteristics, length of stay and discharge outcomes of DDH patients after mechanical ventilation, compared to patients discharged to wards (DW). Of 161 eligible patients, 32.9% were DDH and 68.1% were DW. DDH patients were significantly younger with lower APACHE II scores. They were ventilated for a shorter length of time, and overall length of stay was 7 days shorter. Physical function scores (CPAx) were significantly higher in DDH. There were no differences in re-admission or 90-day mortality. In certain patients, discharge direct to home may be a safe option.

Background: Critical care nurses (CCNs) face difficulties and stress when caring for patients with delirium, and the level of delirium-related stress may be related to gaps in their knowledge and skills.

Aim: This study aimed to assess the impact of a psychoeducational and relaxation program on reducing the stress of CCNs caring for patients with delirium in intensive care units (ICUs) in Taiz city, Yemen.

Methods: From June to the end of December 2022, a quasi-experimental study was conducted among 60 CCNs from two ICUs of Al-Thawra Hospital in Taiz. Demographic characteristics were collected using a pre-designed data collection sheet, and the levels of CCNs' stress were measured using the Delirium Nursing Stress Scale (DNSS). To assess the impact of the developed psychoeducational and relaxation program, stress levels were measured before and after the program, as well as at a 3-month follow-up for long-term impact. The association of demographic characteristics with delirium-related stress was also studied. Data were then analyzed using appropriate statistical tests at a significance level of <0.05.

Results: Before the program, the mean score of CCNs' stress was 60.48 ± 9.51, corresponding to a moderate stress level of 86.7%. However, this score was significantly reduced to 30.98 ± 4.35 immediately after the program and was sustained at 33.13 ± 5.31 3 months after the program, corresponding to a mild stress level. The highest mean score of CCNs' stress related to caring for patients with delirium was observed before the program for all causes of stress on the DNSS, being 4.95 ± 1.77 for the nursing environment, 9.37 ± 2.16 for relationships with peers, 14.40 ± 4.02 for knowledge about delirium, and 31.77 ± 5.78 for nursing practice and work. However, the mean stress scores related to all these causes showed a significant reduction after the program (2.85 ± 0.95, 4.70 ± 1.33, 7.20 ± 1.67, and 16.23 ± 2.80, respectively) and at the 3-month follow-up (3.15 ± 1.05, 4.95 ± 1.23, 7.67 ± 1.66 and 17.37 ± 3.57, respectively). On the other hand, the mean score of total stress for all DNSS items showed a significant reduction from 60.48 ± 9.51 before the program to 30.98 ± 4.35 after the program and 33.13 ± 5.31 at the 3-month follow-up. There were no statistically significant differences in the mean scores of delirium-related stress before and after the program, or at the 3-month follow-up for any of the demographic characteristics of CCNs.

Conclusion: Psychoeducational and relaxation programs have a positive impact on stress reduction in CCNs caring for patients with delirium, improving the standard of care provided to these patients. Regular assessment of CCNs for delirium-related stress and educating them to acquire knowledge and skills are recommended to reduce this stress when caring for delirious patients.

Background: Dysphagia places a substantial burden on the critically ill, affecting 12%-84% of this cohort, and is independently associated with worse outcomes. Pharyngeal electrical stimulation (PES-treatment) is a novel dysphagia therapy with an emerging evidence base. This retrospective observational study describes our dysphagia service and reports the use of PES-treatment as a standard of care in recovering critically ill patients at a single-site tertiary UK hospital.

Methods: Patients admitted to Acute or Cardio-Thoracic adult intensive care units between 1st July 2017 and 30th June 2022 were routinely referred to Speech and Language Therapy (SLT) following tracheostomy, or suspected dysphonia/dysphagia. Clinical assessments and direct laryngeal visualisation using Fibreoptic Evaluation of Swallowing (FEES) were performed. Severe dysphagia was defined as Penetration-Aspiration Score of ⩾6 and patients were offered PES-treatment when staffing allowed.

Results: Of 289 patients with severe dysphagia, 19 underwent a course of PES-treatment with the remaining patients receiving standard care. PES-treatment patients were significantly less likely to remain nil-by-mouth (11.1% vs 62.5%, Chi² p < 0.001) or to have an enteral feeding tube in situ at discharge from critical care (27.8% vs 62.5%, p = 0.006) than those receiving standard dysphagia care. Both groups demonstrated an improvement in Penetration-Aspiration Score at repeat FEES: PES-treatment mean difference -2.0 (p = 0.003); non-PES-treatment -1.68 (p < 0.001); (61% PES-treatment improved vs 40% non-PES-treatment, p = 0.09).

Conclusion: Our observations suggest that PES may be effective in the general critical care population. PES may offer new treatment options for patients and healthcare staff managing severe dysphagia and its significant consequences.