Journal of the Intensive Care Society最新文献

Peer support groups for Intensive Care Unit (ICU) survivors and family members hold promising potential to reduce the psychological burden associated with critical illness and increase social support. We invited all ICU survivors and family members who attended an online peer support group in Ireland ('ICUsteps Dublin' open to those across the Island of Ireland) over a five-year period to complete a brief satisfaction survey. Overall, respondents reported high levels of satisfaction. Four key themes emerged from the open-ended responses: decreased feeling of isolation, gaining insight and perspectives, shared experiences and suggestions for improvement.

Background: Despite advances in sepsis management, the relationship between appropriate empiric antibiotic therapy and acute kidney injury (AKI) in sepsis remains unclear. This study aimed to examine the association of appropriate empiric antimicrobial therapy with AKI in early onset sepsis caused by gram-negative bloodstream infections.

Methods: We conducted a retrospective study of gram-negative bloodstream infection episodes in adult patients with early onset sepsis, using the Premier Healthcare Database from 2016 to 2020. The exposure was appropriate empiric antibiotic therapy determined by antibiotic regiments and antimicrobial susceptibilities of pathogens. The primary outcome was development of AKI or death by day 7 after the onset of sepsis. AKI was defined using the Kidney Disease Improving Global Outcome criteria based on serum creatinine levels, as urine output data were not available. The multivariable regression analysis was used to examine the association between appropriate empiric antibiotic therapy and the outcomes.

Results: We identified 8565 patients with gram negative sepsis. In the total sample, the proportion of appropriate empiric antibiotic therapy was 93.2%, and the prevalence of AKI was 85.3%. Appropriate empiric antibiotic therapy was associated with decreased risk of AKI or death (adjusted odds ratio 0.70, 95% CI 0.52-0.94). For secondary outcomes, appropriate empiric antibiotic therapy was associated with lower AKI, shorter hospital LOS, lower C. difficile infections. However, it was not associated with in-hospital mortality.

Conclusion: Appropriate empiric antibiotic therapy was associated with lower AKI in gram-negative sepsis. Early administration of appropriate antibiotics may prevent development of AKI.

[This corrects the article DOI: 10.1177/17511437251321338.].

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: 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.

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.

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.