Journal of the Intensive Care Society最新文献

Background: We aimed to compare the prevalence and severity of fatigue in survivors of Covid-19 versus non-Covid-19 critical illness, and to explore potential associations between baseline characteristics and worse recovery.

Methods: We conducted a secondary analysis of two prospectively collected datasets. The population included was 92 patients who received invasive mechanical ventilation (IMV) with Covid-19, and 240 patients who received IMV with non-Covid-19 illness before the pandemic. Follow-up data were collected post-hospital discharge using self-reported questionnaires. The main outcome measures were self-reported fatigue severity and the prevalence of severe fatigue (severity >7/10) 3 and 12-months post-hospital discharge.

Results: Covid-19 IMV-patients were significantly younger with less prior comorbidity, and more males, than pre-pandemic IMV-patients. At 3-months, the prevalence (38.9% [7/18] vs. 27.1% [51/188]) and severity (median 5.5/10 vs 5.0/10) of fatigue were similar between the Covid-19 and pre-pandemic populations, respectively. At 6-months, the prevalence (10.3% [3/29] vs. 32.5% [54/166]) and severity (median 2.0/10 vs. 5.7/10) of fatigue were less in the Covid-19 cohort. In the total sample of IMV-patients included (i.e. all Covid-19 and pre-pandemic patients), having Covid-19 was significantly associated with less severe fatigue (severity <7/10) after adjusting for age, sex and prior comorbidity (adjusted OR 0.35 (95%CI 0.15-0.76, p=0.01).

Conclusion: Fatigue may be less severe after Covid-19 than after other critical illness.

Anticipated sequelae of critical care admission for COVID-19 disease remain unclear. Our Edinburgh-based critical care follow-up service identified patterns with nerve injury in 13 of 35 patients who attended following a critical care admission between 15/03/2020 and 25/12/2020. This included 7 cases of meralgia parasthetica, 1 brachial plexopathy, 2 common peroneal neuropathies and 3 ulnar neuropathies. All cases of upper limb neuropathy and foot drop occurred in patients in whom prone positioning was used, with meralgia parasthetica occurring additionally in patients who remained supine.

Background: Combined Lung Ultrasound (LUS) and Focused UltraSound for Intensive Care heart (FUSIC Heart - formerly Focused Intensive Care Echocardiography, FICE) can aid diagnosis, risk stratification and management in COVID-19. However, data on its application and results are limited to small studies in varying countries and hospitals. This United Kingdom (UK) national service evaluation study assessed how combined LUS and FUSIC Heart were used in COVID-19 Intensive Care Unit (ICU) patients during the first wave of the pandemic.

Method: Twelve trusts across the UK registered for this prospective study. LUS and FUSIC Heart data were obtained, using a standardised data set including scoring of abnormalities, between 1^st February 2020 to 30th July 2020. The scans were performed by intensivists with FUSIC Lung and Heart competency as a minimum standard. Data was anonymised locally prior to transfer to a central database.

Results: 372 studies were performed on 265 patients. There was a small but significant relationship between LUS score >8 and 30-day mortality (OR 1.8). Progression of score was associated with an increase in 30-day mortality (OR 1.2). 30-day mortality was increased in patients with right ventricular (RV) dysfunction (49.4% vs 29.2%). Severity of LUS score correlated with RV dysfunction (p < 0.05). Change in management occurred in 65% of patients following a combined scan.

Conclusions: In COVID-19 patients, there is an association between lung ultrasound score severity, RV dysfunction and mortality identifiable by combined LUS and FUSIC Heart. The use of 12-point LUS scanning resulted in similar risk score to 6-point imaging in the majority of cases. Our findings suggest that serial combined LUS and FUSIC Heart on COVID-19 ICU patients may aid in clinical decision making and prognostication.

Background: Disrupted circadian rhythms can have a major effect on human physiology and healthcare outcomes, with proven increases in ICU morbidity, mortality and length of stay.

Methods: We performed a multicentre observational study to study the nocturnal lux exposure of patients in 3 intensive care units.

Results: The median light intensity recorded was 1 lux over the 6-hour recording period; however, this is deceptive as it hides short periods of high lux. When looked at in shorter time segments of 30 minutes, there were significant periods of lux higher than a crude median, especially in higher acuity patients. There was a positive correlation between acuity (as estimated by SOFA score) and maximum lux (R = 0.479, p = .0001), median lux (R = 0.35, p = .006) and cumulative lux (R = 0.55, p = .000001). There was no relationship between neighbouring patient acuity and lux.

Conclusions: Clinicians should practice vigilance at night to provide optimal environmental conditions for patients to minimise potential harm.

Introduction: Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management.

Methods: A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019-2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data.

Results: A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%.

Conclusion: POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Heatstroke represents the most severe end of the heat illness spectrum, and is increasingly seen in those undergoing exercise or exertion ('exertional heatstroke') and those exposed to high ambient temperatures, for example in heatwaves ('classical heatstroke'). Both forms may be associated with significant thermal injury, leading to organ dysfunction and the need for admission to an intensive care unit. The process may be exacerbated by translocation of bacteria or endotoxin through an intestinal wall rendered more permeable by the hyperthermia. This narrative review highlights the importance of early diagnosis, rapid cooling and effective management of complications. It discusses the incidence, clinical features and treatment of heatstroke, and discusses the possible role of intestinal permeability and advances in follow-up and recovery of this condition. Optimum treatment involves an integrated input from prehospital, emergency department and critical care teams, along with follow-up by rehabilitation teams and, if appropriate, sports or clinical physiologists.

Introduction: The age of patients admitted into critical care in the UK is increasing. Clinical decisions for very-old patients, usually defined as over 80, can be challenging. Clinicians are frequently asked to predict outcomes as part of discussions around the pros and cons of an intensive care unit (ICU) admission. Measures of overall health in old age, such as the clinical frailty scale (CFS), are increasingly used to help guide these discussions. We aimed to understand the characteristics of the very-old critically unwell population in the UK and the associations between frailty and outcome of an ICU admission in our healthcare system (National Health Service, NHS).

Methods: Baseline characteristics, ICU interventions and outcomes (ICU- and 30-day mortality) were recorded for sequential admissions of very old patients to UK ICUs as part of the European VIP 1 and 2 studies. Patient characteristics, interventions and outcome measures were compared by frailty group using standard statistical tests. Multivariable logistic regression modelling was undertaken to test association between baseline characteristics, admission type and outcome.

Results: 1858 participants were enrolled from 95 ICUs in the UK. The median age was 83. The median CFS was 4 (IQR 3-5). 30-day survival was significantly lower in the frail group (CFS > 4, 58%) compared to vulnerable (CFS = 4, 65%) and fit (CFS < 4 68%, p = .004). Sequential organ failure assessment (SOFA) score, reason for admission and CFS were all independently associated with increased 30-day mortality (p < .01).

Conclusion: In the UK, frailty is associated with an increase in mortality at 30-days following an ICU admission. At moderate frailty (CFS 5-6), three out of every five patients admitted survived to 30-days. This is a similar mortality to septic shock.

Methods of continuous renal replacement therapy (CRRT) in extracorporeal membrane oxygenation (ECMO) patients include dedicated central venous cannula (CVC) (vCRRT), in-series with filter connected to ECMO circuit (eCRRT) or in-line with haemodiafilter incorporated within ECMO circuit. We assessed the efficacy and safety of eCRRT versus vCRRT in 20 ECMO-CRRT patients. Average filter lifespan was 42 vs 28 hours and filter runs completing 72hours were 40% vs 13.8% (eCRRT vs vCRRT, respectively). One incidence of ECMO circuit air embolus occurred (vCRRT). eCRRT achieved adequate filtration and increased filter lifespan, and has become our default for ECMO-CRRT if a pre-existing dialysis CVC is not present.