Journal of the Intensive Care Society

The report from the Organ Donation Taskforce into the relatively poor rates of donation in the UK called for a complete overhaul of the processes that currently support the identification, referral and management of potential organ donors dying in our hospitals. Although some of the specific recommendations of the Taskforce refer to the responsibilities of national bodies such as the Department of Health or NHS Blood and Transplant, at the very heart of the Taskforce report are those recommendations that are concerned with how the option of donation is made available to patients when they die. Thus, the Taskforce recommended that donation should be a component of end-of-life care, that brainstem death should be diagnosed wherever possible and that potential donors should always be referred according to defined minimum criteria and regardless of apparent donation potential. However, it was recognised that this was unlikely to happen unless every hospital had a team to make it possible - the Donation Committee - that was chaired and driven by a non-clinical champion, enhanced by a donor transplant co-ordinator and lead by a clinician. This paper develops these themes and describes, by focusing on a collaborative relationship between donor transplant co-ordinators and clinical leads for organ donation, how real improvements in the number of organ donors might be achieved.

It has been predicted that in the event of an influenza pandemic in the UK, there could be up to ten times the number of patients requiring critical care support than there are beds available. To aid rational, objective and ethical clinical decision making, the Department of Health recommends using the Sequential Organ Failure Assessment (SOFA) score as a tool for triaging admissions to the critical care unit. This study assessed what effect using the SOFA score would have on capacity. Daily SOFA scores were calculated for all patients on the critical care unit over a one month period. Twenty-four per cent of patients did not meet the criteria for admission to the unit, which would have freed up 36% of bed days in the event of a pandemic. Using this scoring system in conjunction with other measures recommended by the national framework may help the hospital cope with the high demand for critical care beds in the event of an influenza pandemic.

Frightening memories of intensive care, particular delusional memories, such as hallucinations and nightmares, have a powerful adverse effect on psychological health of former intensive care unit (ICU) patients. A diary of the time on ICU can help patients understand what has happened and put any unpleasant memories they may have from their experience into context. Whiston Hospital has used patient diaries since 2002. This article describes how to establish a diary service and how diaries can be used to help patients understand their ICU experience.

Continuity of patient care in the intensive care unit is dependent on reliable and accurate handover. The introduction of shift working for junior doctors as a result of the working time directive has resulted in a minimum of two handovers between medical staff in each 24-hour period. Structure and method of handover has been shown to critically influence the transfer of clinical information vital to the continuity of patient care. We conducted a telephone survey of the intensive care units in the north-west of England to establish details surrounding the methodology of handovers which are currently being used. We established that handovers in our region are generally occurring in a structured manner, but that the quality of handover, information transmitted and personnel present is varied. We advocate the use of a computer-based handover sheet to increase the accuracy of the handover process.

The UK has one of the lowest rates of organ donation in Western Europe. Several barriers to the donation process have been identified. Among these are lack of knowledge, failure of staff to identify potential donors and feeling that it is someone else's responsibility to request for donation. Evidence suggests that educational programmes covering issues regarding organ and tissue donation enhance knowledge and confidence in the organ donation process and ultimately increase the number of potential donors. In 2002, Bolton NHS trust made changes aiming to increase donor rates. Trust study days were introduced, aiming to educate staff about aspects of donation. Since then, Bolton has had a significant increase in donor rates. The purposes of this audit were to assess present levels of knowledge and attitudes about organ and tissue donation and to see whether the introduction of trust study days has made a positive impact amongst critical care staff. The findings of this audit are encouraging, showing a positive impact on both staff knowledge and attitudes towards donation and reflecting a change in culture within the trust.

There is wide variation in infusion practice in UK critical care units. Standardising infusion concentrations may lead to efficiency gains through reduced training burdens, common nomenclature, reductions in error rates and mass production of ready-to-use products by the pharmaceutical industry. A proposed list of standard concentrations for 20 medications given by infusion was produced. Critical care units were surveyed to assess the acceptability of the list for adoption as a national standard; 164 critical care units responded (63% of UK NHS trusts). High acceptance of the list has been shown, with the exception of concentrations of adrenaline, potassium and phosphate where further work is required. The proposed concentrations of the remaining 17 medications should be adopted as a national standard.

The process and techniques of organ transplantation have improved significantly; however, there remains a supply-demand mismatch that appears to grow wider as years go by. In this literature review, databases covering published studies from 1990 to 2006 were searched for studies focused on medical doctors' and/or registered nurses' attitudes towards human-to-human organ donation and/or transplantation. The results indicate that healthcare professionals do play a significant part in the procurement of organs for transplantation and may be partly responsible for the lack of transplantable organs available. However, the review further illustrates their complex role within the healthcare system, and suggests that responsibility for organ procurement may be best placed within the domain of specialist personnel.

Transfusion-related acute lung injury (TRALI), a type of non-cardiogenic pulmonary oedema related to blood transfusion, is gaining prominence as a common adverse event related to blood transfusions in hospitals. Various mechanisms have been postulated to cause TRALI including both antibody-related and non-immune mechanisms. Although transfusion of all types of blood components have been implicated, by far the commonest product related to TRALI was, until recently, fresh frozen plasma, especially that obtained from female donors. However the use of male-only plasma donation in the UK has resulted in an increased observance of TRALI with platelet and red cell transfusions. The diagnosis of this condition is primarily one of exclusion of other causes of pulmonary oedema, with specialist laboratory tests performed to support the diagnosis. The management of TRALI is early diagnosis and good supportive care with, occasionally, ventilatory support. An increased awareness of this complication among intensive care physicians is desirable to prevent one of the commonest and most frequently under-recognised transfusion-related adverse events of the present day.

In critically ill adult patients expected to have an ICU stay greater than 48 hours, the use of an evidence-based protocol for feeding results in improved nutrition but no significant reduction in mortality compared to standard care.

Level of evidence: 1⁺ (RCT with a low risk of bias)

Treating ventilated patients within 72 hours of the diagnosis of acute respiratory distress syndrome (ARDS) with prolonged low dose methylprednisolone leads to a more rapid improvement in lung function and may reduce the duration of mechanical ventilation and ICU stay.

Level of evidence: 1⁻ (RCT with a high risk of bias)

Intensive glucose control with a target blood glucose 4.5–6.0 mmol/L increases the risk of death at 90 days (number needed to harm (NNH)=38) and severe hypoglycaemia (NNH=16).

Level of evidence: 1⁺ (RCT with a low risk of bias)

We report a 63-year-old patient with lateral medullary syndrome secondary to a medullary haemorrhage, causing unilateral vocal cord palsy which precipitated respiratory failure sufficient to warrant intubation and ventilation. The patient recovered completely following neurological rehabilitation and was discharged home a month later. Centrally-mediated vocal cord palsy is a rare cause of stridor, but should be suspected in cases where no other local cause can be found.

The diagnosis and management of broncho-abdominal fistula in critically patients is difficult, with various treatment options including medical, surgical, ventilatory strategies and drainage systems. We report the case of a 58-year-old male patient who presented acutely with systemic sepsis 41 days after undergoing an elective laparoscopic cholecystectomy. The patient underwent a 34-day course of intensive care treatment during which the diagnosis of a broncho-abdominal fistula was made using a simple technique previously undescribed in the critical care literature. The case was subsequently managed successfully following the introduction of high frequency oscillatory ventilation (HFOV) as the principal mode of respiratory support. We describe the unusual presentation, the method of diagnosis and the subsequent management of this case using HFOV.

We describe the case of a young male, found collapsed following poisoning with an unknown substance. He had a Glasgow Coma Score (GCS) of three with a profound metabolic acidosis, despite poisoning with a substance which was strongly basic. He was treated with haemodiafiltration to correct the biochemical derangements. The poison was found to be cyanide, so the patient was also given sodium thiosulphate as an antidote. We review the pathophysiology of cyanide toxicity, the antidotes available and discuss the role of haemodiafiltration in poisoning where the ingested substance is unknown.

Organic solvents are chemically different compounds with one common feature: they dissolve fats, oils and resins, which makes them widely used in industry. Organic solvents are used in paint and lacquer industries, in the production of pesticides, plastics, explosives and in the pharmaceutical industry. The most common household solvent is white spirit, used as a paint remover. We report a case of acute white spirit ingestion causing multiorgan failure and a prolonged intensive care unit admission. Such a case has not been documented previously and highlights a number of diagnostic and therapeutic considerations. The patient also represents the first reported case of chemical burns from erosive diarrhoea secondary to white spirit ingestion.