Journal of the Intensive Care Society最新文献

Background: POCUS is increasingly in utility and application across a variety of specialities. Although several professional societies, including the European Society of Intensive Care Medicine (ESICM) have recommended focussed Neurological ultrasound be a core competency, recommendations on how best to achieve this competency are lacking.

Aim: The purpose of this systematic review was to assess what best-practice and evidence-based recommendations are available to achieve competency in Neurological Point-of-care ultrasound (NeuroPOCUS).

Methods: We undertook a structured systematic review of publications and studies on the training of NeuroPOCUS for intensive care.

Results: Our search strategy yielded a total of 4965 publications, reduced to 3551 following de-duplication. Despite this, only 28 publications were relevant following review of title and abstract and only 12 of these on full-text review. We identified three prospective studies, four consensus statements and five publications as posters and published abstracts. Structured analysis of these revealed minimal evidence-based teaching recommendations, and significant variability in teaching method.

Conclusion: Compared to other modalities of POCUS (e.g. Cardiac and Lung), NeuroPOCUS lags behind with regards to utilisation and training in the general intensive care setting. Further work is needed to establish how this technique can be effectively taught and assessed for clinical application.

Introduction: Non-medical consultant level roles have been in existence for over 30 years, however the number of allied health professionals (AHPs) working at this level, particularly in critical care, remains relatively small. National guidance highlights the importance of clinicians in these roles to work across the four pillars of practice. However, little research exists regarding the roles undertaken by these consultant-level practitioners, the contributions made to service delivery and their perceived impact on patient and service outcomes. Based on this, the aim of this project was to explore the perceived impact of consultant-level AHPs working within critical care.

Methods: Qualitative methodology was used involving a combination of interviews and focus groups. Purposeful sampling was used to recruit AHPs in consultant-level positions within critical care. Senior medical and nursing staff were then recruited via the AHPs. Data were analysed thematically using the Braun and Clarke methodology.

Results: Five consultant-level AHPs were recruited to participate in interviews, with a further 7 participants from senior medical and nursing roles participating in one of two focus groups. The AHPs had been in a consultant-level role for an average of 3.2 years, with all participants reporting over 15 years' experience within critical care. Four core themes were generated from 105 unique codes and 13 subthemes. Personal characteristics were apparent across all themes and therefore was included as a central element. The core themes were (1) scope; (2) status; (3) supportive leadership and (4) impact.

Discussion: Through four core themes, this study has highlighted the roles undertaken by consultant-level AHPs working in critical care, their perceived impact on patient and service outcomes, and their contribution to local, regional and national workstreams. Where these roles exist, they appear to be well received by senior medical and nursing staff, reporting the benefits of highly experienced members of clinical staff to improve service delivery, patient outcomes and contribute to strategic planning.

Around 13% of patients admitted to critical care in Europe die in the Intensive Care Unit (ICU). In the United Kingdom, 15%-20% of patients admitted to critical care do not survive to discharge. Of those that die in ICU, 80% do so following an active decision to withdraw life-sustaining therapy (WLST). With the increasingly aged and co-morbid critical care population entering the ICU, there is an ongoing need for timely, considered discussions both when initiating life sustaining therapies, and also for effective, sensitive communication and management when it comes to withdrawing. In the case of WLST, very little data exists reflecting the proportion of scenarios involving an 'awake' patient with capacity to take part in this decision. It is, however, generally thought to be a small proportion. Most intensivists will therefore have less experience in this process, which perhaps is more representative of the work of our palliative care colleagues. We aim to discuss the most common scenarios in which WLST may occur in the awake and capacitous patient in critical care, the challenges to providing this, and some practical advice on how to perform it well, including the benefits of early interdisciplinary collaboration alongside palliative care.

Introduction: Auto-intoxication represents a considerable number of Intensive care unit (ICU) admissions. Literature focusing on characteristics and outcomes of ICU-admitted auto-intoxicated patients is limited.

Objectives: We aimed to identify the quantity of intensive care admissions attributable to auto-intoxication in a Belgian tertiary center, to examine characteristics and outcomes of these patients, and to assess the impact of the covid-19 pandemic on these variables.

Methods: In this retrospective cohort study, all patients admitted to the ICU of JESSA hospital, Hasselt, Belgium with a diagnosis of auto-intoxication between January 1st 2017 and December 31st 2022, were included in the study. We collected data on patient characteristics, comorbidities, type of intoxication and outcomes including the length of ICU and hospital stay and mortality.

Results: In total, 342 patients were included in the dataset, covering 2.44% of all ICU admissions from January 1st 2017 to December 31st 2022. Although auto-intoxication occurred in all age-categories, the age group from 18 to 29 years old, showed the highest prevalence (24%). More woman (57.6%) than man (42.4%) were included in the study. Of all included patients, 21.6% had a history of previous suicide attempt and 36.5% of previous auto-intoxication. The most common substances ingested were sedatives (44.4%), illicit drugs (20.2%), analgesics (17.8%), and antidepressants (16.7%) whereas in 54.1% of the cases, a combination of substances was ingested. Type of intoxication was separated into four groups: suicide attempt, accidental, iatrogenic and recreational use with suicide attempt accounting for 71.3% of all auto-intoxications. The prevalence of ICU-admitted auto-intoxicated patients remained stable over the 5-year study period. An impact of the Covid-19 pandemic on this prevalence could not be established. Overall mortality was low with an ICU- and hospital mortality of 1.75% and 2.6% respectively. Total mortality at time of dataset closure, on the other hand, was 7.2%.

Conclusions: The impact of auto-intoxication on ICU resource utilization is relatively high and the risk of recidivism is substantial. ICU- and in-hospital mortality after auto-intoxication is low, although these patients have a substantial risk for death in years to come after hospital discharge.

Aim: Levetiracetam is a widely used anti-epileptic in the critical care setting that is almost exclusively (>90%) renally excreted. The altered pharmacokinetics of levetiracetam have been widely studied in intermittent haemodialysis but the evidence and guidance on dosage in continuous renal replacement therapy is varied and poorly defined. Understanding this is critical as a significant number of critically unwell patients develop renal failure requiring continuous renal replacement therapy. The aim of this systematic review is to investigate the pharmacokinetics of levetiracetam in such patients and to understand the implications on dosing strategies.

Methods: A systematic review of the available literature from 2000 to November 2022 was conducted. Seven articles were identified for inclusion from 54 records. A novel hybrid model was developed to evaluate the quality of pharmacokinetic and haemofiltration data. This data was used to develop a one-compartment model that simulated dosing strategies in 10,000 patients based on an assumed steady state of 72 hr and target trough concentrations of 12-46 mcg/mL.

Results: From the seven articles included, pharmacokinetic data was retrieved for 24 individual patients. Total clearance was 3.49-4.63 L/hr (mean 3.55, S.D. 0.52). Elimination half-life was 5.66-12.88 hr (mean 9.41, S.D. 2.86). Volume of distribution was 0.45-0.73 L/kg. The proportion of total clearance attributable to continuous renal replacement therapy was 52%-73% (mean 54.7%, S.D. 13.5). Our simulations demonstrate that more than half of patients who received twice daily doses of 750 mg or greater without a loading dose achieved therapeutic drug concentrations. The time to achievement of therapeutic drug concentrations was greatly reduced by the addition of a 60 mg/kg loading dose (up to a maximum of 4.5 g). The use of a reduced loading dose or twice daily doses of 500 mg or less without loading were more likely to result in prolonged sub-therapeutic drug concentrations.

Conclusion: Levetiracetam clearance in haemofiltration is similar to healthy adults with normal renal function (GFR > 90 mL/min). The use of reduced doses due to renal failure in critically ill patients may result in sub-therapeutic drug concentrations in a high number of patients. A twice daily dosing of 750-1000 mg with an initial loading dose of 60 mg/kg should be considered in such patients alongside therapeutic drug monitoring.

Hypertonic saline (HTS) may have anti-inflammatory properties. We aimed to investigate the effect of pre-hospital HTS on neutrophil to lymphocyte ratio (NLR), a simple marker of systematic inflammation, in patients with severe traumatic brain injury (TBIs). We included 110 adults with blunt TBIs requiring pre-hospital anaesthesia (median age 57.1 years, 67% male). On hospital admission, median NLR was lower in patients who received pre-hospital HTS (7.9 vs 11.9, p = 0.021), and in multivariable analysis, HTS use remained associated with NLR (p = 0.048). We believe our findings highlight the neuroinflammatory properties of HTS as an area for future research.

Trace elements are required in minute quantities in the diet but play a vital role in a wide variety of functions, such as co-factors in antioxidant reactions and normal immune function to DNA and protein synthesis and skeletal and tissue remodelling and repair. Critically ill patients are at risk of trace element deficiency or excess, due to changes in intake, absorption, metabolism or excretion. Deficiency or excess can lead to a wide range of cellular and organ dysfunction that may be seen in patients with an acute or critical illness, including cardiomyopathy, impaired glucose tolerance and reduced oxygen delivery. In addition, various diseases, such as systemic inflammation and renal and intestinal failure, and intensive care treatments, such as parenteral nutrition, renal replacement therapy and diuretics, can increase the likelihood of deficient or excessive amounts of micronutrient levels. This narrative review discusses sources and normal physiology of trace element handling and how this may be impaired in critically ill patients. It then discusses various conditions seen in critically ill patients that may be caused or exacerbated by abnormal trace element status and the current evidence around whether supplementation is of benefit in particular critical illnesses.

Background: The lighting environment in intensive care units (ICUs) is markedly different from natural light, potentially disrupting patients' circadian rhythms and impacting staff wellbeing. New lighting technologies may mitigate these effects.

Methods: A mixed methods service evaluation was conducted in a London ICU using Dyson Lightcycle™ luminaires (DLs) to evaluate staff wellbeing. Wellbeing assessments and user perceptions of the built environment were conducted using validated questionnaires before, during, and after DL deployment. Existing ambient light usage was measured using HOBO devices installed on the ceiling. Additionally, data on DL usage (including spectral data) were collected continuously using Raspberry Pi™ sensors.

Results: DL usage was high (>70% per 24 h), primarily as supplementary lighting. Users found DLs easy to control and beneficial for clinical and administrative tasks. Participants assigned a 12.5% higher satisfaction score rated from 0 to 8 of lighting overall during deployment compared to pre-deployment (6.06 ± 0.29 and 5.06 ± 0.60, respectively; p = 0.20). Control variables for the built environment (noise, temperature and air quality) remained unchanged. Staff reported improvements in mood (38%, p < 0.001), fatigue (17.7%, p < 0.001), and sleep quality (21.2%, p = 0.01) during DL use.

Discussion: In the first pilot feasibility service evaluation of its kind, the relationship between ICU lighting quality and staff wellbeing was investigated using DLs. We show that it is feasible to equip an ICU with a novel mode of lighting to evaluate both illuminance and user-centred outcomes. The study suggests a positive association between DL use and staff wellbeing, with notable improvements in mood, fatigue and sleep quality. The nature of the emitted light may enhance the space rather than simply illuminate, thus further adding to a feeling of wellbeing. These findings support data from studies which report effects of light brightness and colour on mood. Additionally, there appears to be a signal towards benefit to the user when additional lighting is provided, compared to the current overhead fluorescent luminaires prevalent in most ICUs. In this service evaluation these benefits were demonstrated in ICU staff operating the device. However, it is conceivable that effects such as improved mood and reduced sleep disturbance may have patient benefits too.

Conclusion: Local lighting systems like DLs show promise in enhancing ICU staff wellbeing. Their impact on patient outcomes and the potential for broader implementation deserve further investigation in appropriately designed and powered larger-scale trials.

Background: Community acquired pneumonia (CAP) is a common cause of hospital admission. CAP carries significant risk of adverse outcomes including organ dysfunction, intensive care unit (ICU) admission and death. Earlier admission to ICU for those with severe CAP is associated with better outcomes. Traditional prediction models are used in clinical practice to predict the severity of CAP. However, accuracy of predicting severity may be improved by using machine learning (ML) based models with added advantages of automation and speed. This systematic review evaluates the evidence base of ML-prediction tools in predicting CAP severity.

Methods: MEDLINE, EMBASE and PubMed were systematically searched for studies that used ML-based models to predict mortality and/or ICU admission in CAP patients, where a performance metric was reported.

Results: 11 papers including a total of 351,365 CAP patients were included. All papers predicted severity and four predicted ICU admission. Most papers applied multiple ML algorithms to datasets and derived area under the receiver operator characteristic curve (AUROC) of 0.98 at best performance and 0.57 at worst, with a mixed performance against traditional prediction tools.

Conclusion: Although ML models showed good performance at predicting CAP severity, the variables selected for inclusion in each model varied significantly which limited comparisons between models and there was a lack of reproducible data, limiting validity. Future research should focus on validating ML predication models in multiple cohorts to derive robust, reproducible performance measures, and to demonstrate a benefit in terms of patient outcomes and resource use.