Journal of the Intensive Care Society最新文献

Background: Major trauma is a significant global health issue. Pneumonia poses an additional risk for morbidity and mortality after major trauma yet identifying pneumonia remains challenging in clinical practice. This systematic review aims to evaluate blood-based biomarkers for pneumonia in major trauma patients.

Methods: The search was performed across four databases up to November 18th 2024, including primary studies investigating blood-based biomarkers associated with pneumonia in adults hospitalised after major trauma (PROSPERO CRD42024542059). Risk of bias was assessed using the ROBINS-E tool and meta-analysis was performed of pooled data.

Results: Among 20 included studies, with a total of 4316 participants, the pooled mean pneumonia rate was 32.7% (23.5%-43.4%). Seventy biomarkers for post-operative pneumonia were identified, with meta-analysis possible for 12 of the reported biomarkers. At admission interleukin (IL)-6 (standardised mean difference: 1.41 (0.04-2.77), p = 0.04), cytokeratin fragment 21-1 (CYFRA21-1; 0.53 (0.19-0.86), p = 0.002) and leucocyte count (0.28 (0.05-0.50), p = 0.01) were higher in patients who developed pneumonia. During hospitalisation, patients with pneumonia had significantly higher IL-10 (4.42 (3.89-4.95), p > 0.001) and neutrophil oxidative burst capacity (1.52 (0.96-2.09), p > 0.001) at day 1, CYFRA21-1 at day 2 (0.43 (0.10-0.76), p = 0.01), IL-6 at day 3 (3.11 (2.66-3.55), p > 0.001) and day 5 (0.57 (0.05-1.09), p = 0.03) and CRP at day 4 (1.87 (1.51-2.24), p > 0.001), day 5 (1.38 (1.03-1.72), p > 0.001), day 6 (0.74 (0.42-1.06), p > 0.001) and day 7 (0.87 (0.12-1.63), p = 0.02). Across the included studies, 85% exhibited some concerns to very high risk of bias.

Conclusions: While we identified potential candidate biomarkers for pneumonia in major trauma patients, the high heterogeneity across trauma populations, clinical diagnostic tools and biomarker testing methods warrants further high-quality studies to confirm their clinical value.

The Intensive Care Society and Faculty of Intensive Care Medicine are pleased to launch revised procedural checklists, Local Safety Standards for Invasive Procedures (LocSIPPs) that we hope will improve the safety of our intensive care units. First produced in 2017, the updates take into account learning from reported patient safety incidents, some of which have been associated with considerable morbidity and mortality. The publication of NatSIPPs 2 has been acknowledged during the update. We have focused on procedures which are commonly performed in Critical Care Units (intubation, bronchoscopy, intercostal drain insertion, tracheostomy insertion, central venous catheter insertion). The checklists have been designed to enable departments to use and adapt to make them unit specific. They will require relevant educational and clinical governance procedures to accompany them, to fit into local working practices.

Subarachnoid hemorrhage (SAH) refers to intracranial bleeding into the cerebrospinal filled space beneath the arachnoid membrane that covers the brain. It is further defined as a spontaneous SAH when not associated with trauma. The commonest single cause is rupture of a saccular (i.e. a small bag-shaped or pouch-shaped) intracranial aneurysm, arising from the larger conducting arteries traveling through the subarachnoid space at the base of the brain. As these are high-pressure and higher-volume arterial hemorrhages, aneurysmal subarachnoid hemorrhages (aSAH) are associated with high early mortality and substantial long-term morbidity. But, as we outline below, prompt and collaborative multidisciplinary care can improve the likelihood and quality of survival. Accordingly, we offer the following primer as a common resource to increase knowledge and collaborative care.

Little is known about the effect of alternative patient routes prior to ICU admission on clinical outcomes. Therefore, this study compared patients that were admitted directly from the emergency department into the ICU with those admitted from the wards. Patients admitted from the wards had significantly higher SOFA (6 vs 5, p = 0.038) and APACHE scores (19 vs 16, p = 0.007), as well as a greater need for invasive ventilation (45.5% vs 28.6%, p < 0.001). Hence, this hypothesis-generating study suggests that further work is needed to assess if scoring systems are sensitive enough to assess the need for ICU admission.

Background: Critically ill patients are at risk of bleeding from stress ulcers. Comprehensive information regarding United Kingdom stress ulcer prophylaxis (SUP) practices are not available and may change over time. We aimed to describe SUP practices in 2020 and reevaluate the position in 2024.

Methods: Critical care pharmacists provided observed SUP practice data for UK adult critical care units via an electronic repository in 2020 and 2024. One response was accepted from each critical care unit at each time point. Data collected included trigger criteria for commencing SUP, primary medication class used, primary SUP cessation criteria, and level of nutritional intake (if part of cessation criteria).

Results: There were high response rates of 70.3% (2020) and 66.7% (2024) of registered UK adult critical care units. Few differences in primary SUP trigger criteria between 2020 and 2024 were seen, with small differences in the categories of 'SUP not used' (p = 0.002) and 'Shock' (p = 0.027) driving statistical significance (χ²(7, 454) = 16.76, p = 0.019). There was a significant change in the primary medication class used for SUP (H2 receptor antagonist 49.4% 2020, vs 0.4% 2024, proton pump inhibitor 44.7% 2020 vs 97.8% 2024; χ²(2, 458) = 159.62, p < 0.001). Primary SUP cessation criteria was 'Patient fed' (66.8% 2020, 64.6% 2024), with most describing this threshold as met when the patient receives full enteral feed (72.0% 2020, 78.8% 2024).

Conclusion: The UK has moved towards proton pump inhibitors as the primary SUP medication class. SUP is most frequently discontinued on establishment of enteral nutrition.

Introduction: Early rehabilitation of critically ill patients is challenging due to limited staff resources. This study assessed the feasibility of delivering a randomised controlled trial of physiotherapy assistants delivering early protocolised rehabilitation plus usual care compared with usual care.

Methods: We conducted a randomised feasibility study in three U.K. mixed medical/surgical intensive care units. Eligible patients were intubated and ventilated <72 h, expected to be ventilated for a further 48 h, and functionally independent before ICU admission. Patients were randomised to protocolised early rehabilitation plus usual care or usual care. Feasibility outcomes were (i) recruitment of one to two patients/per month/site; (ii) >75% of patients commencing the intervention within 72 h of ventilation with >70% interventions delivered; and (iii) blinded outcome measures recorded at three-time points in >80% of patients.

Results: The study delivery was compromised by the COVID-19 pandemic: 46 patients were enrolled, of which 22 were allocated to intervention. Feasibility outcomes: (i) recruitment of 0.9 patients/month/site, (ii) 90% of patients commenced interventions within 72 h of ventilation, with 166/264 (63%) of study interventions delivered: median total 22.5 min (IQR 15-35) of therapy per day in the usual care group and 45 min (IQR 25-70) in the intervention group, and (iii) the outcome assessments were performed at three-time points for 64% of survivors, 63% of which were blinded.

Conclusion: While delivery of protocolised rehabilitation by physiotherapy assistants is feasible, the design of a future RCT needs to consider strategies to improve recruitment and complete blinded outcome assessments.

Background: Socioeconomic inequalities in chronic disease management and outcomes are well-established. Their association with critical illness management and outcomes is less clear. This study aimed to investigate the association between socioeconomic status and outcomes following emergency admission for critical illness.

Methods: Three Scotland-wide health databases were linked: the Scottish Intensive Care Society Audit Group database (critical care units); the Scottish Morbidity Record 01 (hospital admissions) and death certificates. A retrospective cohort study was conducted on adults (⩾16 years) admitted as an emergency to critical care units between 25th October 2010 and 25th October 2021 inclusive. Cox proportional hazards models were used to investigate the association between area-based socioeconomic status (Scottish Index of Mortality (SIMD) decile) and all-cause mortality, adjusting for potential confounders: age, sex, comorbidities, illness severity, and diagnostic group. Secondary outcomes included unit and hospital lengths of stay, and emergency hospital readmissions.

Results: Overall, 50,914 patients were included in the cohort. Those in the least deprived decile were less likely to die (_adjHR 0.85, 95% CI 0.79-0.92), had 19% longer critical care unit stays (95% CI 13-26) and a 12% longer hospital stays (95% CI 7%-18%). Over the subsequent year, the least deprived had significantly fewer emergency hospital re-admissions (_adjIRR 0.73; 95% CI 0.67-0.81).

Discussion: People living in the most deprived communities have worse outcomes following emergency admission to critical care; particularly in the longer term and reinforcing the need to address socioeconomic inequalities in healthcare access and outcomes.

Accurate stroke volume (SV) assessment is crucial in ischaemic cardiogenic shock. While pulmonary artery catheterisation remains the gold standard, its invasive nature necessitates reliable noninvasive alternatives. However, the literature on echocardiographic SV accuracy is inconsistent. This study evaluated commonly used echocardiographic techniques-Doppler-derived and Simpson's method-against invasive thermodilution in 39 patients. SV by Doppler showed strong correlation (r = 0.91, p < 0.0001) and minimal bias, whereas the Simpson's method exhibited weaker correlation and more significant underestimation. These findings suggest Doppler echocardiography as the more accurate noninvasive tool for SV estimation, addressing prior discrepancies and enhancing haemodynamic management in critical care.