Journal of the Intensive Care Society最新文献

Background: Radial arterial catheters are frequently used for monitoring and blood sampling in critical care patients. Ischaemic complications are rare but can cause significant morbidity. The use of vascular ultrasound in critical care is becoming increasingly commonplace. This service evaluation aims to assess the feasibility of training novices in advanced vascular ultrasound assessment, prior to radial arterial cannulation.

Methods: Over a 4-month period, data was collected from patients admitted to the intensive care unit at the William Harvey Hospital, Ashford, Kent. Ultrasound was used to assess for the presence, size and flow of the radial and ulnar arteries. The assessments were performed by two novice residents in intensive care, who were trained in advanced ultrasound assessment of the radial and ulnar arteries, by an intensive care consultant with expertise in vascular ultrasound.

Results: One hundred and five limbs were assessed in 53 patients. Novices were deemed to be sufficiently competent, after performing scans on 15 patients over a 2-week period. Satisfactory images were acquired in 100% of patients. The most common finding was a small diameter ulnar artery, present in 30 limbs (29%), while only 1 patient (1%) was found to have an absent ulnar artery. Thirty-two limbs had a radial arterial catheter in-situ. There were no ischaemic complications.

Conclusion: This service evaluation demonstrates that the training of novices in advanced ultrasound assessment of the radial and ulnar arteries by an intensive care consultant, is feasible. Moreover, this modality may identify patients at risk of critical limb ischaemia. This particular investigation may be considered for incorporation into existing vascular ultrasound assessments.

Background: Intensive care unit (ICU) survivors in the United Kingdom (UK) can receive support from ICU follow-up services in their process of recovery and rehabilitation. However, it is unclear whether the COVID-19 pandemic impacted the ability of UK hospitals to provide follow-up. The objective of this study was to evaluate the provision of follow-up services in the UK for adult survivors of COVID-19 critical illness.

Methods: All adult National Health Service (NHS) ICUs in the UK were invited to participate. Intensive care clinicians aware of follow-up services offered at their site were invited to complete a self-administered online electronic survey. Free text answers were thematically analysed.

Results: 174 of 242 (71.9%) NHS hospitals responded to the survey. 140 (80.5%) of the respondent hospitals had an ICU follow-up service for survivors of COVID-19 critical illness. A new service was created at 28 (16.1%) hospitals during the COVID-19 pandemic. ICU follow-up services were mostly delivered by nurses (125/140, 89.3%), ICU doctors (111/140, 79.3%), physiotherapists (88/140, 62.9%) and psychologists (59/140, 42.1%). Where ICU follow-up services already existed, changes were made in 111 (79.3%) hospitals during the pandemic and these were maintained in 89 (80.2%) hospitals. Funding was a commonly reported reason for whether follow-up services were offered.

Conclusions: There was an expansion in the number of ICU follow-up clinics, and the multidisciplinary team delivering post-ICU care to patients who survived COVID-19 critical illness. Many changes to clinic operations introduced during the pandemic persisted, including the use of virtual and hybrid follow-up clinic models.

Background: Beta-blockers have been studied for potential benefits in traumatic brain injury (TBI). This study aimed to investigate the association between early beta-blocker exposure and brain injury biomarkers following moderate-severe TBI.

Methods: We conducted a retrospective cohort study using data from the Transforming Clinical Research and Knowledge in TBI (TRACK-TBI) study. Patients ⩾ 17 years with moderate-severe TBI (Glasgow Coma Scale 3-12) admitted to an intensive care unit (ICU) were included. Early beta-blocker exposure was defined as administration within the first 72 h of admission. The primary outcome was blood-based brain injury biomarker levels on day 3 post-injury. Biomarkers included glial fibrillary acidic protein (GFAP), ubiquitin C-terminal hydrolase-L1 (UCH-L1), neuron-specific enolase (NSE), S100 calcium-binding protein B (S100B), and the inflammatory biomarker C-reactive protein (CRP). Propensity-weighted models analyzed the association between beta-blocker exposure and biomarker levels.

Results: Among 450 patients, 31 (7%) received beta-blockers (BB+). The mean (SD) age of BB+ patients was 51.4 (16.2) years, compared to 39.5 (17.0) years for unexposed patients (BB-). BB+ group was associated with a decreased NSE level on day 3 (ratio = 0.71, 95% CI 0.52-0.96, p = 0.026), although this was not significant after adjusting for multiple comparisons (p = 0.13). For secondary outcomes, UCH-L1 levels increased on day 5 in the BB+ group (ratio = 1.62, 95% CI 1.12- 2.36, p = 0.011), but this was not significant after adjustment (p = 0.55). The NSE level on day 14 decreased in the BB+ group (ratio 0.45, 95% CI 0.30-0.66, p < 0.001) and remained significant after adjustment (p = 0.005).

Conclusions: There was no association between early beta-blocker exposure and the primary outcome which was blood-based brain injury biomarker levels on day 3. In exploratory analysis, we found that early beta-blocker may associated with decreased NSE level on day 14. Due to the retrospective nature of the study and the use of propensity-weighted analysis to identify associations, direct clinical practice changes cannot be recommended. However, the significant association with NSE level warrants further investigation through prospective studies or randomized controlled trials to confirm the potential neuroprotective effect of early beta-blocker exposure on neuronal cellular injury.

Background: Hypermetabolism and enteral nutrition delivery challenges, result in trauma patients, becoming malnourished during their hospital, admission. This study aimed to explore enteral nutrition delivery, predictors of suboptimal delivery and the relationship with clinical outcomes in patients admitted to a critical care unit following major trauma.

Methods: An exploration of nutrition related data collected as part of a multicentre prospective major trauma study was conducted. Nutrition related data included anthropometry, nutrition risk screening, feeding route, nutrition products, target volume, nutrition delivery and causes of enteral feeding interruptions. Multivariate logistic regression analysis was used to evaluate the strongest associations with suboptimal nutrition delivery.

Results: Of 1036 participants, 71% (n = 732) required enteral nutrition for a mean of 15.7 (7.9) days. Suboptimal nutrition delivery was prevalent throughout the admission. Mean energy target was 23.8 (6.37) versus 15.81 (3.43) kcal/kg/day delivered (p < 0.001). Mean protein target was 1.27 (0.34) versus 0.89 (0.48) g/kg/day delivered (p < 0.001). Factors associated with suboptimal nutrition delivery included male sex (OR, 1.82, 95% CI 1.27-2.60; p < 0.001), traumatic brain injury (OR, 1.67, 95% CI 1.16-2.40; p = 0.006) or high NUTRIC score (OR, 1.17, 95% CI 1.08-1.27; p < 0.001); early enteral nutrition reduced the risk of underfeeding (OR, 0.49, 95% CI 0.30-0.81; p = 0.006). Lower energy and protein delivery were associated with increased days of mechanical ventilation (p < 0.001) and longer length of stay in both the critical care unit and overall hospital stay (p < 0.001).

Conclusion: Trauma patients experience inadequate enteral nutrition delivery which potentially negatively impacts clinical outcomes. Additional investigation is required to further understand the barriers and facilitators to adequate nutrition provision in critically ill trauma patients.

Background: The English National Health Service (NHS) is a publicly funded system, however significant disparities in provision exist. Whereas the national picture of the distribution of Intensive Care Unit (ICU) beds has increased over time, less is understood about the regional variation in the rate of growth in ICU services and whether this is related to population growth. The aim of this study was to describe the national variation in the supply of ICU beds in England and evaluate whether there has been a narrowing of the regional disparities in providing ICU beds over time.

Methods: Population-based panel analysis of ICU bed supply over a 10-year period, 2012-2021. Data were obtained from publicly available national resources. Descriptive analyses were summarised and trends examined. Disparity gap of ICU beds were calculated for each region. A fixed-effect panel data regression model was used to see the effect of unobserved variables on ICU bed supply for a particular region compared to the country average. Sub-group analysis was done for those 65 years and over.

Results: Overall, ICU beds increased by 9.9%, resulting in a 2.2% increase in ICU beds per 100k population and a decrease by 5.1% in those aged 65 years and over. Between regions, ICU beds per capita varied over time, with a decrease in the South East but an increase in all other regions. In the population aged 65 years and over, the variation of a decrease in ICU beds was more pronounced, with the largest impact in the South East. To increase regional ICU bed capacity to the same as London, which was the region with the highest per capita, for total population, an uplift of 29% to 109% of ICU beds is required and 104% to 246% in those 65 years and over. The unobserved variables have the highest positive impact in ICU bed supply in London and the highest negative impact in the Midlands.

Conclusion: ICU bed supply showed significant regional variations across England. We did not identify any significant narrowing of the regional disparities in provision of ICU beds over time. Further research should focus on better understanding the policy framework that underlies the regional supply of healthcare.

Necrotizing enterocolitis (NEC) is a potentially fatal comorbidity of prematurity with one in five affected requiring surgical intervention. Despite its seriousness, there is lack of objective radiographic criteria on plain abdomnial radiographs (X-ray) to guide prognosis and decision making. Point of care bowel ultrasound (BUS) provides a more dynamic assessment and more information around bowel health. However, there is lack of widespread adoption of this practice by neonatologists due to training opportunities and inconsistent support from radiologists. We present a feasibility study from UK of using point of care bowel ultrasound in conjunction with X-ray to aid diagnosis of NEC. We report that that neonatologist performed BUS when used as an additional diagnostic aid has a higher positive predictive value and specificity compared to X-rays alone. Features like absent or poor peristalsis and abnormal bowel perfusion were the most consistent pathological findings in our cohort. Wider implementation of this practice is limited by training opportunities and dedicated support from radiology team.

This review by the Legal and Ethical Advisory Group (LEAG) summarizes the important legal cases and prevention of future deaths (PFDs) ruled or issued in 2023 that are pertinent to Intensive Care Medicine. The legal cases include human rights cases, clinical negligence 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.

Debate exists about the safety of inserting central venous catheters (CVC) and central venous dialysis catheters (CVDC) ipsilaterally, lest the catheter tips lie in close proximity risking direct aspiration of vasopressors from the CVC into the CVDC. This study showed that ipsilateral or contralateral placement did not affect the distance between CVC and CVDC line tips. There were no significant adverse changes in cardiovascular parameters or noradrenaline dose when CRRT was commenced regardless of whether the lines were inserted ipsilaterally or contralaterally.