Journal of the Intensive Care Society最新文献

The provision or withholding of Cardiopulmonary Resuscitation (CPR) is often a source of much controversy. Do-Not-Attempt CPR (DNACPR) decisions have been discussed extensively from an ethical and legal point, not to mention featuring heavily in the news. We aim to discuss various aspects of DNACPR decision-making with particular relevance to the Intensive Care environment. In doing so, we highlight important concepts associated with decision-making and common challenges encountered. Firstly, we provide a broad oversight of the current context in which such decisions are made before describing the principal ethical points of consideration and their relevance. This is followed by insights from a legal point as well as practical suggestions for approaching such decisions. It is hoped that these will help to assist clinicians with making such complex decisions under challenging circumstances.

Severe community-acquired pneumonia (sCAP) is associated with a significant health burden, both in the UK and globally, with intensive care support needed for many patients. The high morbidity and mortality associated with sCAP has led to the exploration of adjunctive therapies that may help reduce disease burden and improve clinical outcomes. One such proposed treatment is corticosteroids, aiming to moderate the disproportionate inflammation caused by sCAP. Despite several studies suggesting potential benefits, the use of corticosteroids in patients with sCAP remains contentious, with recent large trials producing conflicting results. These variations in trial outcomes have resulted in conflicting national and international guidelines. Such discrepancies align with findings from a recent national survey that indicated ongoing clinical uncertainty regarding the use of corticosteroids for sCAP in UK intensive care units. Several factors contribute to these conflicting outcomes, including patient population, the severity classification utilised, the type and duration of interventions provided, and, perhaps most importantly, the lack of pre-phenotyping to identify patients who may benefit most from the treatment. This narrative review aims to examine the recent literature, current guidelines, and evidence for using corticosteroids in sCAP, while exploring the candidate phenotypes of relevance in the design of clinical trials.

Background: Improved survival from critical illness in recent years has led to an increase in patients with Post Intensive Care Syndrome (PICS). Routine, dedicated, specific and individualised assessment, rehabilitation and follow-up after critical care discharge is recommended but is currently inadequate in the UK. The aim of this study was to explore patients' and family members' experiences of a critical care admission, focussing on recovery and rehabilitation.

Methods: As part of an intervention development programme, a series of iterative focus groups with survivors of critical illness and their family members was held. Parallel groups with staff involved in the care and rehabilitation of critically ill patients were also conducted. Participants mapped out their recovery journey identifying key moments and challenges and shared their recommendations for recovery and rehabilitation. Brokered dialogue was used to enable patient and staff groups to ask and answer questions of each other. Data analysis was completed using reflexive thematic coding.

Results: Thirty-four participants attended the focus groups, with 28 attending the first two groups discussed in this paper. Using the experiences described by the participants, three overarching themes were identified; fear, helplessness and frustration. Participants also reported both short and longer-term consequences of ICU admission and shared their priorities and advice for recovery and rehabilitation.

Conclusion: Critical care admission is a traumatic experience for patients and family members. Our data highlights patients' needs for ongoing, holistic support during a stay in critical care and beyond.

Background: Increasing numbers of patients with cancer are being admitted to intensive care units (ICU) with sepsis. The mortality from sepsis and septic shock in these patients is unclear. This study aimed to establish mortality from sepsis and septic shock in patients with cancer admitted to ICU and assess mortality trends over time.

Methods: We conducted a literature search using MEDLINE and EMBASE. Included studies enrolled adult patients with cancer admitted to ICU with sepsis or septic shock and reported outcomes of interest. Studies were assessed using the Newcastle-Ottawa Scale for risk of bias and the quality assessment tool for observational cohort and cross-sectional studies. We performed a meta-analysis to estimate pooled ICU, hospital and 30-day mortality from sepsis and septic shock and a multivariate meta-regression to assess mortality trends over time. The study was registered on PROSPERO (CRD42022341277).

Results: Twenty-five articles were included. The pooled ICU, hospital and 30-day mortality for sepsis was 44% (95% CI 38%-50%), 54% (95% CI 49%-60%) and 49% (95% CI 44%-55%) respectively. The pooled ICU, hospital and 30-day mortality for septic shock was 51% (95% CI 45%-57%), 62.6% (95% CI 56%-69%) and 54% (95% CI 46%-61%) respectively. There was significant heterogeneity between studies. The meta-regression identified decreasing ICU and hospital mortality from sepsis, and decreasing ICU mortality from septic shock.

Conclusion: Patients with cancer admitted to ICU with sepsis face a significant mortality risk greater than that of the general population, despite decreasing mortality over time. Further research is required to improve outcomes.

This review by the Legal and Ethical Advisory Group (LEAG) follows the 2023 summary, reviewing the important legal cases and Prevention of Future Deaths reports (PFDs) ruled or issued in 2024 that are pertinent to Intensive Care Medicine. The legal cases include Human Rights cases, Clinical Negligence cases, and rulings of the Court of Protection. Not all of the cases relate to events which have occurred in Intensive Care, however the rulings will have a bearing on Intensive Care practice.

Right ventricular injury (RVI) is a frequent complication during veno-venous extracorporeal membrane oxygenation (VV-ECMO) for severe respiratory failure. In this single-centre retrospective cohort of 40 patients, RVI was observed in 63%, being associated with increased ICU mortality. RVI at admission was more common in younger patients and those with shorter intubation periods pre-cannulation. RVI developing during VV-ECMO was associated with longer ECMO support, ICU stay, and a trend towards higher mortality. The timing of RVI likely reflects different pathophysiology, having different clinical implications. Improved monitoring of right ventricular function during VV-ECMO may enable earlier detection and intervention, potentially improving outcomes.

Point-of-care echocardiography accreditation is not mandated within the Faculty of Intensive Care Medicine (FICM) training curriculum, yet it is commonly utilised to aid clinical decision making in the intensive care unit. We designed a survey to assess barriers to accreditation in point-of-care echocardiography across Scottish critical care units. The majority (70.1%) of respondents were unaccredited, with the most common barrier (n = 102) being 'lack of time with a mentor for supervised scanning'. This was amplified by the fact that only 25% of mentors received job planned time for scanning. Men were over-represented in those with accreditation, accounting for 61.4% of accredited clinicians, despite making up 51.0% of all respondents. In contrast, women represented 62.5% of unaccredited individuals who had undertaken at least one attempt at the process. We did not find a difference with other protected characteristics. This survey suggests that targeted support locally for those struggling to complete the process could address some of these concerns, and that further work needs to be taken to identify and address gender inequity in point of care echocardiography accreditation.

We evaluated whether non-invasive estimated inspiratory muscle pressure (P_mus) predicts extubation outcomes in ICU patients. Estimated P_mus, reflecting the pressure generated by respiratory muscles, was measured before and after the spontaneous breathing trial (SBT). Lower pre-SBT estimated P_mus (<4.1 cmH₂O) and post-SBT (<4.4 cmH₂O) were associated with extubation failure (AUC ≈ 0.73). P0.1 and dynamic transpulmonary pressure (P_L,dyn) showed no significant association. Estimated P_mus offers a simple bedside method to assess inspiratory muscle strength and may help identify patients at risk of extubation failure. Further multicenter studies are needed to validate these findings.

Objective: A scoping review was performed to understand the extent and type of published evidence in relation to restricting feeding of critically ill patients to the daytime only, with a nighttime fasting period.

Introduction: Time-restricted feeding has been shown to be beneficial to long-term health. Critically ill patients admitted to intensive care units (ICUs) are traditionally fed continuously. The potential benefits or harms of daytime only feeding in the critically ill are unknown.

Inclusion criteria: Studies of critically ill patients, cared for in any critical care environment, where feeding was stopped for a minimum of 6 h overnight, with any primary outcome, were included.

Methods: Using the JBI framework, a search of OVID Embase, OVID Medline, CINHAL, PROSPERO, The Cochrane database and Web of Science was performed in July 2023.

Results: Fourteen studies that included 868 participants, published between 1989 and 2023 met the inclusion criteria and were reported on. The patient cohorts were from general or mixed ICUs, and neurosurgical and paediatric cohorts. Feed was either administered by bolus, in cyclic patterns or continuously. The overnight fasting times ranged from 6 to 12 h, with reported primary outcomes of feed intolerance, nutritional delivery, ketosis, gastric pH, ventilator associated pneumonia and circadian rhythms. Daytime only feeding was found to increase ketosis and lower gastric acidity.

Conclusions: Daytime only feeding in the critically ill has been reported, but details of its potential harms or benefits are limited by inconsistently defined outcomes and study small sample sizes.

Enhanced recovery after surgery (ERAS) programmes are well established across many surgical specialties. Successful implementation requires both multidisciplinary engagement and active patient participation. At our hospital, many patients were unaware they had a role in their recovery. To improve education, we developed a poster highlighting seven key elements using the acronym PROMOTE: Pain relief, Respiratory exercises, Own clothes, Mobilisation, Oral hygiene, Taking away attachments, and Eating and drinking. Feedback from patients in the post-operative critical care unit showed the resource was well received, easily understood, and most wished they had received it pre-operatively to help manage expectations and reduce anxiety.