Journal of the Intensive Care Society最新文献

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.

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.