Journal of the Intensive Care Society最新文献

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.

Background: The formation of anastomoses between the pulmonary arteries and pulmonary veins, or the pulmonary and the bronchial circulation, is part of normal foetal lung development. They persist in approximately 30% of adults at rest, and open in almost all adults during exertion. Blood flowing through these anastomoses bypasses the alveolar surface and increases in such shunting can thus cause hypoxaemia. This is now known to contribute to the pathogenesis of hypoxaemia in COVID-19 disease. We here provide evidence to support a similar role in influenza A infection.

Illustrative case presentation: We describe a case of influenza A infection associated with severe hypoxaemia, poorly responsive to supplemental oxygen and which worsened following the application of continuous positive airway pressure (CPAP), despite the presence of a normal physical examination, chest radiograph and echocardiogram. This combination suggests a significant intrapulmonary (extra-alveolar) shunt as a cause of the severe hypoxaemia. The shunt fraction was estimated to be approximately 57%.

Discussion and conclusion: Intrapulmonary vascular shunts can contribute substantially to hypoxaemia in viral infection. Seeking to understand the pathogenesis of observed hypoxaemia can help guide respiratory therapy. Mechanistic research may suggest novel therapeutic targets which could assist in avoiding intubation and mechanical ventilatory support.

There are no guidelines for assessing and communicating the expected difficulty of a tracheostomy, leading to difficulties planning a percutaneous approach in intensive care or referring onwards to surgical teams. A Delphi process was used to develop a tool containing metrics which are relevant for either specialty and can be universally assessed by both. Palpable tracheal rings, prior surgery or radiotherapy to the anterior neck, uncorrectable clotting or platelet dysfunction, ability to extend the neck freely, and overlying vessels visible, palpable or on imaging were all found to be relevant. It is hoped this tool will aid communication between specialties.