Journal of the Intensive Care Society最新文献

The use of high flow nasal oxygen (HFNO) in clinical practice is increasing with robust evidence of its respiratory benefits. Swallowing is known to be heavily coordinated with breathing, in addition to sharing a physical pathway in the upper airway. Applying HFNO via these spaces may also have an impact on the swallowing process. Yet, there is a lack of literature regarding the effect of HFNO on swallowing and on dysphagia. This narrative review aims to summarise the existing literature, draw conclusions on important clinical questions where possible and set the scene for future research. A database search was conducted on 24/01/2024 across CINAHL, Medline and Embase. Due to paucity of literature, studies with adult participants within and outside of ICU were included, and references cross-checked. Conference abstracts were also included. The search was repeated on 5/6/2024. Twelve articles were included in direct data comparison, in addition to studies examining the biomedical effect of HFNO that is, the impact of HFNO on the physiology of the oropharynx and swallow function. The authors conclude that whilst studies are limited in numbers and some results controversial, indications are that HFNO may demand adaptations to swallowing and some patients may not have this capability to adapt. HFNO should not be a barrier to a swallow assessment, irrespective of flow rate and the decision to assess should be based on overall patient presentation, as with any other population. Instrumental swallowing assessment is recommended to confirm any detrimental or beneficial impact of HFNO on swallow function. Robust research and guidelines are needed.

Pleural procedures are fundamental skills for intensive care specialists. While competency in these procedures is not explicitly mandated within the Intensive Care Medicine (ICM) curriculum, achieving proficiency remains a vital goal for ICM trainees. Anecdotal evidence suggests that training in this area is often perceived as inadequate, with considerable variability in practice across intensive care units (ICUs). We conducted the first survey of ICM trainees in the UK to evaluate routine practices, formal training, accreditation, and perceived competence. The findings revealed significant gaps in training. Confidence levels in performing chest drain varied widely, and a notable deficiency in thoracic ultrasonography (US) training was identified. Additionally, it was observed that many ICUs frequently rely on non-ICM specialists to perform pleural procedures. These results underscore critical areas for improvement within ICM training. The authors advocate for enhanced education, structured training programmes, and increased support to address these deficiencies. This will ensure that trainees and future consultants are adequately equipped to perform pleural procedures with confidence and competence.

Background: Between April 2022 and March 2023, 43.8% (88,259) patients admitted to Intensive Care Units (ICU) in the United Kingdom (UK) required breathing support through a ventilator, the majority require sedation. Unfortunately, mechanical ventilation is associated with high mortality and morbidity, and sedative agents currently used have significant side effects including hypotension and delirium. They are also implicated in long-term psychological sequelae such as major depression and posttraumatic stress disorder. Ketamine has been utilised in anaesthesia for over 50 years and has an excellent safety profile. The diverse properties of ketamine are the focus of much research currently, including its properties as a potent antidepressant. Ketamine has not been fully investigated in the context of ICU, and there are gaps in the evidence that warrant further investigation through a large randomised controlled trial. Preparatory work for such a study includes refining study designs, identifying key clinical and patient centred outcomes and exploring barriers to implementation, which is the focus of this work.

Methods: SHOCK-ICU is a single centre, non-randomised, feasibility study assessing the feasibility of continuous ketamine infusions for the provision of sedation for 30 patients undergoing mechanical ventilation on the ICU.Data will be collected at baseline, daily until >48 h without mechanical ventilation, ICU discharge, and 90-days from enrolment. Data collection will include trial aspects such as expected recruitment, refusal, and follow-up rates, ability to collect data, and exploratory assessment of clinical efficacy markers.

Primary outcome: The primary outcome is study feasibility; this will be assessed using pre-defined progression criteria that will aid design of future ketamine sedation studies.

The use of corticosteroids in severe community-acquired pneumonia (sCAP) management is a contentious issue with current practices of United Kingdom (UK) intensivists largely unknown. To investigate this, we surveyed UK intensive care clinicians from 20 September 2024 to 19 December 2024, collecting 160 responses from 115 intensive care units (response rate 48.3%). 56.1% of responders use corticosteroids in the treatment of sCAP. There were large variabilities in practice. Hydrocortisone started within 24 h of admission 50 mg four times a day for 4-5 days was the most reported regime. The variation in practice coupled with relative equipoise requires further evaluation and guidance.

Background: Spinal cord injury (SCI) is a devastating condition with a high burden of morbidity and mortality. National guidelines state that patients should not receive enteral feeding for 48 hours after inury, which may be detrimental if a patient experiences a hypercatabolic response to polytrauma. We conducted a systematic review of the benefits and harms of delayed enteral feeding in this population.

Methods: We searched MEDLINE, EMBASE and Cochrane CENTRAL for studies which had a time parameter as part of their evaluation of feeding in the acute phase of spinal cord injury in a critical care setting. Required outcomes for inclusion were neurological improvement, neurological complications, time spent in an ICU, time to ICU discharge, incidence of secondary complications, other adverse effects and mortality. Risk of bias was assessed with the Downs and Black checklist.

Results: Four studies met the inclusion criteria. There was no high-quality evidence of worsened outcomes with earlier feeding compared to delayed enteral feeding. One study demonstrated that patients fed before 24 h in conjunction with a broader bundle of care had improved neurological outcomes compared to previous non-standardised practice. There was no evidence of difference in frequency of infections or mortality in early or late feeding groups.

Conclusions: We find no clear evidence of increased risk of harm from earlier enteral feeding strategies, nor clear evidence of benefit of earlier feeding as an isolated intervention.

Objective: This retrospective observational study conducted in a general ICU aimed to evaluate the hemodynamic impact of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration.

Design: The study was designed as a retrospective observational study in a general ICU setting.

Setting: The study was conducted in a general intensive care unit (ICU).

Patients: Data from 498 patients receiving IV paracetamol in various clinical contexts were analyzed.

Interventions: Patients received IV paracetamol for analgesia and fever reduction as part of their clinical care.

Measurements and main results: The study analyzed the hemodynamic effects of IV paracetamol by monitoring blood pressure, urine output, and core temperature post-administration. A significant decrease in mean systolic and diastolic blood pressure values was observed across different patient subgroups, notably 45-60 min post-infusion. An increase in noradrenaline dosage and a decrease in urine output indicated a decline in end-organ perfusion following IV paracetamol administration. Multivariate analysis identified associations between clinical factors (such as general anesthesia and cardiac conditions) and changes in blood pressure.

Conclusions: While IV paracetamol remains a valuable therapeutic option for pain and fever management, especially in hypertensive patients with specific conditions like traumatic brain injury and cerebral vascular accident, careful monitoring, and individualized dosing strategies are recommended in critically ill patients to maintain hemodynamic stability and optimize clinical outcomes. These findings contribute to enhancing our understanding of IV paracetamol hemodynamic effects and inform evidence-based practices for its use in ICU settings.

Background: Critical care nurses experiencing high levels of emotional exhaustion (EE). However, limited studies explored the association between generational differences and nurses' perceived EE. The objectives of the current study were to: (1) assess generational differences in EE among critical care nurses and (2) examine the link between nurses' EE and the generational differences, occupational stress, structural empowerment, and nurses' perceived work environment.

Methods: A proportional stratified clustered sampling technique was utilized. The hospitals were stratified according to their location. Data were collected from nurses working at 19 hospitals in Oman. The emotional exhaustion sub-scale of the Maslach Burnout Inventory was used to assess the level of EE among nurses working in critical care units.

Results: A total of 714 staff nurses participated. The majority (78%) were from generation Y and 22% were from generation X. Regression analysis showed that generation Y critical care nurses experienced higher EE levels than generation X nurses. Increased psychological stress among nurses was associated with increased EE. Higher levels of access to support, resources, and information, as well as supportive managerial leadership and sufficient staffing and resources, were associated with significant reductions in EE.

Conclusion: To reduce job burnout among critical care nurses, healthcare leaders are required to ensure adequate staffing, provide managerial support, and monitor stress and EE levels frequently, particularly among generation Y nurses.

Background: We assessed the healthcare and economic burden of sepsis in adult hospitalised patients in Wales, UK.

Methods: We analysed hospital admissions to all acute hospitals in Wales via the Secure Anonymised Information Linkage Databank. We included all adult patients, 2006-2018, with an inpatient admission including one or more explicit sepsis codes.

Results: 38,564 patients had at least one admission for sepsis between 2006 and 2018. Most persons (86.7%) had just one admission. 3398 patients (8.4%) were admitted to ICU. The number of admissions increased yearly over the study period from 1548 in 2006 to 8708 in 2018. The largest annual increase (141.7% compared to the previous year) occurred in 2017. Admission numbers increased disproportionately amongst patients with high levels of comorbidities, but changes were consistent across all age groups, areas of deprivation and ICU admissions. Estimated inpatient sepsis costs were £340.34 million in total during the study period. The average cost per hospital spell was £7270. Patients readmitted to the hospital for sepsis amassed estimated treatment costs of over £72 million during the study period. Out of the 38,564 persons, 21,275 (55.2%) died within 3 years of their first admission. Inpatient mortality halved from 40.5% to 19.5%, and there was a trend towards reduced mortality at 6 months, 1 and 3 years post hospital discharge.

Conclusion: Sepsis related hospital admissions are increasing over time and still likely to be underreported. Although mortality appears to have fallen, prolonged hospitalisation and readmissions place a significant burden on healthcare system resources and costs.