Journal of the Intensive Care Society最新文献

We present a case of a class 3 drowning event with severe sand aspiration, successfully managed with mechanical ventilation, bronchoalveolar lavage, ECMO, and the use of a mechanical insufflation-exsufflation device (MI-E). Sand aspiration is a potentially lethal consequence of near-drowning events. It may cause respiratory failure by several mechanisms, including laryngospasm, upper or lower airway obstruction and an intrinsic acute respiratory distress syndrome (ARDS) related to the sand itself. Its standard management involves lung-protective mechanical ventilation strategies, bronchoalveolar lavage, and, more recently, extracorporeal membrane oxygenation (ECMO) in adult and paediatric cases. MI-E devices are commonly used by physiotherapists in the intensive care setting to facilitate secretion clearance in extubated patients, reducing the occurrence of ventilator-associated pneumonia. However, their use in intubated patients in the UK is not as common due to a lack of evidence and experience. The evidence supporting their use in intubated patients is of low quality, and we have not found any examples of their use for clearing aspirated particulate matter or in conjunction with ECMO in the literature. We believe this is the first time MI-E has been used this way. We argue that it could be a valuable addition to the management of sand and other particulate aspirations, even in severe cases requiring ECMO, and it warrants further exploration. Using a MI-E device may significantly decrease the duration of ECMO treatment, reducing its associated complications and expenses.

[This corrects the article DOI: 10.1177/17511437241311087.].

Background: Delirium is a severe neuropsychiatric clinical state presenting as an acute onset of cognitive deficits. Patients receiving invasive mechanical ventilation (IMV), have the highest incidence (50%-80%) of delirium amongst patients admitted to intensive care units. Preliminary data indicates that early mobilisation is associated with reduced delirium in critically ill patients. However, definitive evidence is lacking. Current practice varies due to many barriers to patients, who require IMV, receiving early mobilisation interventions. In-bed cycling may address some of these barriers. This research aims to evaluate the feasibility and acceptability of early in-bed cycling to reduce delirium in critically ill patients.

Methods: This multi-site feasibility randomised controlled trial will evaluate early (⩽48 h following IMV), in-bed cycling as a method of early mobilisation, to reduce delirium. Eighty-four participants will be randomised across three sites in a 1:1 ratio, to receive either early in-bed cycling in addition to usual care or usual care alone. The primary outcome is feasibility (recruitment, retention, intervention fidelity). Secondary outcomes include different methods of measuring delirium, physical function, length of stay, ventilator free days, sedation free days, Richmond Agitation Sedation Scale, adverse events and mortality. Descriptive statistical analyses will be conducted. Hypothesis testing will be used for exploratory analysis of the mechanistic sub-study outcomes. An embedded qualitative interview study will evaluate the acceptability of this research.

Conclusion: This trial has been prospectively registered (ISRCTN74277350) and received full ethical approval (REC reference: 24/SC/0096). The trial opened to recruitment in July 2024. Recruitment will take place across 18-months.

Background: There are theoretical reasons why beta-lactam antibiotics may be more effective in treating severe infections if administered by continuous infusion, rather than short intermittent infusions. The Beta-Lactam Infusion Group (BLING) III trial was a multinational randomised clinical trial (RCT) which tested this hypothesis in participants with sepsis who were cared for in an intensive care unit (ICU). The United Kingdom (UK) findings are reported here.

Methods: The global trial was an open-label RCT conducted in the UK, Australia, New Zealand, Belgium, France, Sweden and Malaysia. Participants were critically ill adults being treated with meropenem or piperacillin/tazobactam due to a confirmed or presumed infection. Participants were randomised to receive the antibiotic by either continuous infusion or short intermittent infusion at equivalent daily doses as selected by the treating team. The primary outcome was 90-day all-cause mortality; secondary outcomes included clinical cure up to 14 days after randomisation, new infection and acquisition of resistant organisms, ICU and in hospital mortality.

Results: Overall, 7202 participants were randomised, with 2900 from the UK. The UK cohort had very similar baseline characteristics and outcomes to the global trial. For continuous versus intermittent infusion, the global trial showed 24.9% versus 26.8% participants had died by 90 days (odds ratio 0.91, 95% CI: 0.81-1.01, p = 0.08); and in the UK 26.7% versus 29.3% participants had died (odds ratio 0.88, 95% CI: 0.75-1.04, p = 0.13). Although not statistically significant, all outcomes showed point estimates in favour of continuous infusion.

Conclusions: The findings in the UK cohort are consistent with the conclusions drawn from the global BLING III trial. It seems reasonable to conclude the finding are applicable to the UK.

Background: Airway clearance is a vital aspect of respiratory care in patients with severe acute respiratory failure receiving veno-venous extracorporeal membrane oxygenation (VV-ECMO). These patients often receive high levels of sedation alongside ultra-lung protective invasive mechanical ventilation, which, while reducing ventilator-induced lung injury, significantly impairs physiological mechanisms essential for secretion clearance, such as expiratory flow bias, mucociliary transport, and effective cough.

Objectives: This commentary explores the multifaceted challenges to airway clearance in the VV-ECMO population, evaluating current physiotherapeutic interventions, and identifying critical areas for future research.

Discussion: Ultra-lung protective ventilation settings reduce airflow and expiratory shear forces necessary for secretion mobilisation. Concurrent sedation and neuromuscular blockade suppress cough reflexes and promote secretion stasis, while reduced airflow impairs the two-phase gas-liquid flow critical for airway hygiene. Additionally, increased secretion viscosity and altered lung mechanics further limit clearance. Current physiotherapy strategies such as suctioning, hyperinflation, cough augmentation, and manual techniques are often adapted from non-ECMO settings and lack validation in this population. Diagnostic challenges, such as reduced auscultation efficacy, highlight the growing importance of tools like lung ultrasound. Pharmacological adjuncts, including mucolytics and saline lavage, are used despite limited supporting evidence.

Conclusion: Airway clearance in patients receiving VV-ECMO is hampered by a convergence of physiological, mechanical, and clinical factors. Existing literature remains scarce and largely extrapolated from conventional invasive mechanical ventilation populations. There is an urgent need for targeted research to define evidence-based interventions tailored to the unique pathophysiology of this complex group.

Focused echocardiography plays a vital role in assessing donor hearts and improving donor utilisation in the United Kingdom. A NHS Blood & Transplant working group was established and, through a review of the current evidence and modified Delphi approach, developed guidance for a minimum dataset for image acquisition in donor heart assessment. This is in intended as a pragmatic optional supplementation to current focused echocardiography protocols. We present a donor echocardiography proforma with accompanying educational materials for use in the United Kingdom.

Introduction: Survival rates for cardiac arrest remain low. Extracorporeal cardiopulmonary resuscitation (ECPR) may offer a survival advantage in carefully selected patients. There is limited published data on ECPR in the UK and therefore this study aims to describe the last 11 years provision and outcomes of ECPR in the UK.

Methods: This was a multicentre retrospective cohort study in the UK. Centres offering Extracorporeal membrane oxygenation (ECMO) as a potential support in the UK were identified at the first UK ECPR Summit. All centres were asked to submit data on their veno-arterial (VA) ECMO and ECPR patients between 1st January 2012 and 31st December 2022.

Results: Over the 11-year period, 2117 patients received VA-ECMO in the UK with 963 survivors at 6 months (45.5%). Of these there were 302 ECPR runs with 92 survivors (30.5%). ECPR contributed to 14.3% of the total VA ECMO runs, with wide between-centre variation ranging from 5.4% to 73.3%. Centres provided a detailed dataset for 129 of the 172 consecutive ECPR cases for a 5-year period to 31st December 2022. The mean (SD) age was 46 ± 5 years, 77% were male and 48.9% presented with a shockable rhythm. The leading cause of cardiac arrest was ischaemic heart disease (45%). Only 14% achieved transient or sustained return of spontaneous circulation prior to initiation of ECMO flow, with mean time CPR to full ECMO flow of 52.5 ± 17.1 min. Percutaneous cannulation was performed in 85.3% of cases, with 51.9% of these procedures taking place in the cardiac catheter laboratory.

Conclusion: In an UK cohort of VA ECMO and ECPR patients, the survival rates were comparable to other international registries. The variation in practice highlights the need to explore and address inequity of access to ECMO and ECPR services.