Journal of the Intensive Care Society最新文献

Background: Potential organ donors are often identified in intensive care following brainstem or circulatory death. Clinical optimisation is fundamental for maintaining organ viability and physiotherapists are well positioned to support this through targeted interventions. Despite this, the physiotherapy role in deceased organ donation remains underexplored. This study aimed to describe current practice and explore the perceptions of physiotherapists in the United Kingdom involved in managing deceased organ donors.

Methodology: An explanatory sequential mixed methods design was utilised. An online survey was used to describe the national picture of current physiotherapy practice. Online semi-structured interviews were undertaken to explore perceptions and attitudes of physiotherapists towards the physiotherapy management of deceased organ donors.

Results: Fifty-six physiotherapists completed the survey, with 52% (n = 29) reporting involvement in donor management "always," or "most of the time." Treatment aims included secretion clearance (49%, n = 26) and lung optimisation (45%, n = 24). Suctioning was the most frequently performed intervention (95%, n = 53), followed by positioning (71%, n = 40) and manual techniques (71%, n = 40). Only 5% (n = 3) reported having local guidelines. Seven physiotherapists participated in interviews, identifying six key themes: experiences, barriers, role perceptions, physiotherapist learning needs, multidisciplinary team learning needs, and future needs.

Discussion: The role of physiotherapy in organ donor management is under-recognised and lacks national consensus. Findings highlight disparities in practice, limited guidance and the need for further training to strengthen clinical reasoning. Guidance development that addresses the practical, ethical and emotional complexities of this work is urgently needed to support physiotherapists in this evolving area.

Neurological emergencies such as stroke and traumatic brain injury are major contributors to morbidity and mortality in critically ill patients. These conditions frequently result in alterations in cerebral haemodynamics, including raised intracranial pressure, which require timely recognition and management to optimise outcomes. Neuro point-of-care ultrasound (NeuroPOCUS), incorporating transcranial Doppler (TCD), transcranial colour-coded duplex (TCCD) ultrasound, and optic nerve sheath diameter (ONSD) measurement, offers a non-invasive, bedside means of assessing cerebral physiology and is increasingly recognised as a valuable adjunct in neurocritical care. Despite the successful adoption of point-of-care ultrasound in critical care through established accreditation pathways such as FUSIC^® and CACTUS^®, the UK has lacked a dedicated framework for NeuroPOCUS. To address this gap, we have developed and launched a UK-specific NeuroPOCUS accreditation programme, combining structured theoretical teaching with supervised practical training. The pathway addresses the distinct needs of both paediatric and adult populations, combining theoretical learning with practical application. Core learning materials include neuroanatomy, Doppler principles, standardised insonation techniques, and interpretation of cerebral blood flow velocities and indices such as pulsatility (PI) and resistivity (RI). Supporting resources feature videos of transcranial colour-coded Duplex (TCCD) imaging in normal subjects and clinical case examples. Participants will complete a logbook of 50 supervised cases, facilitated by remote mentorship. A novel accreditation pathway provides an opportunity for further research into the use of NeuroPOCUS in neurocritical care. This article outlines the core techniques of NeuroPOCUS, the physiological insights it offers, key clinical applications, and the proposed accreditation pathway aimed at standardising practice and clinician training in the care of critically ill patients with neurological injury or dysfunction.

Accurate estimation of right atrial pressure (RAP) is crucial in cardiogenic shock, yet echocardiographic surrogates are often unreliable. In this exploratory analysis of 43 patients with ischaemic cardiogenic shock, pulmonary artery catheter-derived RAP was compared with right heart echocardiographic indices. Only right ventricular e' velocity demonstrated a weak correlation with RAP (rho = 0.31, p = 0.04), but did not significantly discriminate elevated pressure. Other Doppler and morphometric measures showed no meaningful associations. Echocardiographic parameters correlated poorly with invasive RAP, indicating that conventional indices cannot reliably substitute for pulmonary artery catheterisation in assessing venous congestion in this population.

In 2023, the Intensive Care Unit at the Dudley Group NHS Foundation Trust became the first in the UK to achieve Gold Standards Framework (GSF) accreditation. This study evaluates the impact of GSF implementation on end-of-life care delivery and associated metrics. Coding of end-of-life care increased from 10.7% to 16.1% and the proportion of deaths recognised as GSF Amber/Red rose from 14.5% to 58.1% with an increased number of referrals to Specialist Palliative Care. GSF accreditation was associated with sustained improvements in key end-of-life care metrics in intensive care, enhancing collaboration with Specialist Palliative Care and supporting more individualised, patient-centred care.

Assessment and support of hypoxic patients is common in intensive care medicine. Simple oxygen therapy systems are typically used at the beginning of the patient journey, but their performance is influenced by the device used and the patient's respiratory pattern. A solution to overcome this issue is presented, which eliminates device factors and the patient's respiratory pattern from early simple medical gas administration; whereby an oro-nasal mask uses a novel interface combined to visual feedback. The resultant accuracy of medical gas administration achieved, should aid early assessment, support, and rescue of patients in respiratory distress.

Background: In sepsis and cardiac arrest, arterial hypotension is associated with poorer outcomes, including renal injury and mortality. Guidelines recommend a mean arterial pressure (MAP) target of ⩾65 mmHg, but supporting evidence is limited. We undertook a service evaluation which aimed to: (1) assess clinical opinion regarding the optimal MAP target in intensive care (ICU); and (2) evaluate MAP target adherence at the Royal Infirmary Edinburgh ICU, quantifying levels of hypotension.

Methods: We utilised a concurrent triangulation mixed-methods approach, integrating semi-structured consultant interviews and quantitative analysis of patient-level blood pressure data. Blood pressure data were collected at 1-min intervals for the first 72 h of arterial monitoring. We defined hypotensive insults by five sequential minutes below MAP target.

Results: We interviewed 18 consultants. Twelve (67%) reported a standard target of 65 mmHg. The importance of evidence-based, individualised, and flexible targets was emphasised. We included 208,570 min of monitoring time across 66 patients. At admission, 53 (80%) patients received a target of 65 mmHg. Mean (SD) MAP was lower in patients on vasopressors than those not on vasopressors (77.6 (14.2) vs 86.9 (17.3) mmHg, p = 0.0001). Hypotension affected 55 (83%) patients and accounted for >10% of monitoring time in thirteen (20%). Median pressure-time index (PTI) was 3.4 mmHg * h; 24 (36%) patients had a PTI >10 mmHg * h.

Conclusions: The optimal MAP target varied by patient, yet target personalisation remained limited in practice. Target adherence varied, with observed MAP both exceeding and undershooting set targets. Future research will explore the feasibility and implications of achieving tighter blood pressure control.

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.