Journal of the Intensive Care Society

The aim of the Cardiac Output Monitoring EvaluaTion-UK (COMET-UK) study was to update reports of cardiac output (CO) monitoring use and to examine whether there is any association between the frequency of CO monitoring use in adult, general intensive care units and patient outcomes. Questionnaires were sent to all intensive care units in England, Wales and Northern Ireland (n=221) asking whether the unit had used CO monitoring in the last two years and, if so, to give details of average frequency of use and which CO monitors were available. The majority of units (n=100, 45.2%) used CO monitoring most days or a few times a week and 33 (14.9%) monitored CO every day (response rate 100%). The most commonly available methods were oesophageal Doppler (n=127, 57.5%), LiDCO (n=96, 43.4%) and PiCCO (n=92, 41.6%). There was no significant difference in risk-adjusted acute hospital mortality (p=0.25) or length of stay (p=0.48) across categories of frequency of use. However for ventilated vs non-ventilated patients and different quartiles of illness severity, there was an association between higher frequency of use and worse outcome among non-ventilated and lowest risk admissions quartiles. The COMET-UK study found that CO monitoring is in common use; however, there was no evidence that more frequent use of CO monitoring was associated with improved outcomes.

This is a pilot study, comparing two commonly-used weaning techniques in patients with a tracheostomy to establish if one technique resulted in shorter time to successful weaning. In a prospective, single-centre randomised, controlled trial, conducted in a 15-bed multidisciplinary intensive care unit, fifty patients mechanically ventilated for at least 48 hours and who had a tracheostomy inserted primarily for weaning purposes, were randomised to one of two weaning techniques: increasing periods of spontaneous ventilation, or reducing pressure support ventilation. Each technique was protocolised for implementation by the nursing staff and consisted of two stages: a weaning and a verification stage. This pilot study did not find a statistically significant difference in the length of time spent weaning when two nurse-led protocolised weaning techniques of increasing periods of spontaneous ventilation or reducing pressure support ventilation were compared in patients with a tracheostomy inserted primarily for weaning purposes. No safety issues were identified in either protocol.

Recent military operations have highlighted the role of the Defence Medical Services in the management of casualties with complex traumatic injury. This article outlines the provision of intensive care support during deployed operations.

‘Protective ventilation’ for acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) is a major advance in intensive care medicine. However, components of protective ventilation expose the right heart to challenges. Acute cor pulmonale (ACP), patent foramen ovale (PFO) and right ventricular failure (RVF) are recognised complications that could potentially reduce the benefit of protective ventilation. We sought to determine the rates of ACP, PFO and RVF in critically ill adults undergoing protective ventilation with ARDS/ALI and to identify their impact on mortality and critical illness acuity. A comprehensive search of electronic databases including Medline (OVID, EmBase) and CINAHL (EBSCO) was undertaken, including Cochrane Library and international registries, between January 1991 and December 2011. A systematic review identified a total of 248 articles; 27 were reviewed in full and 22 studies were included. All 22 included studies were observational or quasi-experimental with no randomised, controlled trials available. ACP was present in 16–100%, PFO 1.3–22.0% and RVF 9.6–26.0%. Neither ACP nor PFO was associated with an adverse effect on mortality and ACP seemed reversible in survivors; however both ACP and PFO were associated with prolonged need for ICU support. RVF was variously associated with no increase in mortality to an odds ratio 5.1 for death in multivariate analysis. There was marked heterogeneity in the studies included, explaining the range of observed values. Recommendations for future research and practice were produced. Modern protective ventilation during ARDS has been shown to exert inconsistent effects on the right heart which may be of clinical significance. Further research is needed to determine these effects better.

Since the Department of Health Report ‘Paediatric Intensive Care: A framework for the future’ in 1997, paediatric intensive care services have been centralised and 24-hour retrieval services developed. However, all hospitals admitting critically ill children must be able to resuscitate and stabilise prior to retrieval, and occasionally undertake the ‘time-critical’ transfers themselves. This article reviews the clinical and organisational skills involved in the retrieval process, and also suggests ways in which knowledge and skills can be maintained.

Interhospital transfer of critically ill patients is a task frequently delegated to doctors-in-training. However, previous studies have shown them to be ill prepared for this task, prompting the inclusion of transfer medicine as a domain in both anaesthesia and intensive care curricula, though not as yet in emergency medicine. Given the change and variation in curricula, we surveyed anaesthesia and emergency medicine trainees in the West of Scotland to gauge their experience of and training in interhospital transfers. Our results showed trainees continuing to conduct solo interhospital transfers from an early stage in their careers without specific training. Redressing this shortfall in training is imperative, particularly as centralisation of services will require more frequent transport of greater numbers of critically ill patients by trainees. We speculate about why these deficits in transfer training persist and how they might be remedied, particularly given the proposed integration of specialist transport teams in Scotland.

As our population ages, there will be an increasing number of extreme elderly patients (aged 85 years and older) admitted to intensive care units (ICUs). Relatively few studies are published about clinical outcomes in this population. We analysed three years of admissions data to the ICU of a teaching hospital in the West Midlands for patients who were aged 85 years or older at time of admission to ICU. Data from 185 patient episodes were included in the analysis. Six-month mortality in medical and surgical emergency patients was 62.5% and 55.1% respectively. Mortality was low in elective surgical patients at 18.6%. For those who survived the acute hospital admission, 68% of patients were discharged home, with a further 17% moving to a rehabilitation facility. A significant proportion of extreme elderly patients admitted to the ICU are surviving critical illness despite advanced age. The majority of survivors returned home, indicating that they were making a positive functional recovery from their illness.

Intensive care staff may harbour mixed emotions toward organ donation after circulatory death. We wished to compare these attitudes to donation after brainstem death, as well as explore attitudes toward Specialist Nurses in Organ Donation, who have been embedded into UK intensive care units since 2008. At the Mid-Trent Critical Care Network (MTCCN) annual conference, participants were asked, in small group workshops, to write down words they associated with donation after brainstem death, controlled donation after circulatory death and Specialist Nurses in Organ Donation. The words were later collated and assigned to have either a positive or negative association by three blinded individuals: a medical lawyer, a hospital communications manager and a final year medical student. One hundred and eight intensive care staff participated: 24 (22%) doctors, 61 (57%) nurses and 23 (21%) allied health professionals; 75 (69%) of the participants were female. Participants at the workshop offered a total of 211 words, 93 associated with donation after brainstem death (44%) and 118 (56%) associated with controlled donation after circulatory death. The numbers of positive and negative words associated with the two forms of donation were significantly different (p<0.001) (donation after brainstem death - 68 positive words, 25 negative words; donation after circulatory death - 29 positive words, 89 negative words). This difference remained significant (p<0.001) even after all words (n=48) that did not have unanimous agreement between the three blinded word assigners were excluded. Significantly more positive words (95) were attributed to the Specialist Nurse in Organ Donation than negative words (18) (p<0.001). We conclude that this group of intensive care staff were generally positive toward donation after brainstem death and the embedded Specialist Nurse in Organ Donation, but could harbour negative attitudes toward controlled donation after circulatory death. Only by continuing to address the opinions of healthcare professionals will donation after circulatory death become a usual and not an unusual event.

The government has recently increased the retirement age and as a result doctors are going to have to work longer. Intensive care medicine is a demanding specialty with significant on-call commitment, and this paper looks at the potential ramifications of this policy change on patient safety and personal health of intensivists. All consultants working in Wales with sessions in intensive care medicine were asked to complete a survey to ascertain their opinion on whether increasing age would affect patient safety or their personal health. If asked to work beyond the age of 60, 80% of respondents thought that patient safety would be jeopardised and 67% of respondents felt their personal health would be affected. Twenty-seven respondents (43%) have had or currently have health problems linked with work, and this correlates with the intensity of the on-call (p<0.004). Intensivists have substantial concern about whether increasing the retirement age is a realistic proposition in this specialty. If a consultant feels that he or she is not providing safe care it is important that the problem can be raised and addressed with the full support of the employers and the profession, and without penalty.

Cardiac abnormalities following blunt chest trauma can range from minor ST changes to arrhythmias, cardiac rupture, cardiogenic shock and death. A normal electrocardiogram (ECG) on presentation does not guarantee the absence of myocardial injury, and with no gold standard test to detect the condition, myocardial contusion is often identified only at autopsy. We describe the late presentation of evolving and dynamic conduction abnormalities on the ECG, including a sinusoidal conduction pattern, in a young trauma patient. This sequence of conduction abnormalities has not previously been observed and we discuss the potential explanations.

A 51-year-old man developed rhabdomyolysis and multiple organ failure following infection with Salmonella lohbruegge. This species was resistant to ciprofloxacin. After the patient was bacteria free, he continued to have symptoms due to adhesions and strictures until he had a defunctionning ileostomy performed surgically. According to the national reference laboratory, only two such cases have been isolated in the UK since 2004 in addition to this one. Since 1991, 12 human cases and five non-human cases involving snakes, lizards, shrimps and a chicken have been reported.

A 47-year-old man presented with severe acute pancreatitis, thought to be hypertriglyceridaemia-induced. Serum triglyceride concentration fell from 42.4 mmol/L to 5.9 mmol/L by day three with fasting alone. Hypertriglyceridaemia precipitates a small but significant proportion of acute pancreatitis episodes, especially during pregnancy. Treatment strategies are discussed, with special focus on plasmapheresis. The reduction in serum triglyceride concentration achieved by plasmapheresis is similar to that achieved by fasting alone, or in conjunction with insulin or heparin therapy. It is possible that plasmapheresis may offer the patient more harm than benefit. Currently, there is insufficient evidence to either recommend or reject plasmapheresis in triglyceride-induced acute pancreatitis.

The use of illicit substances is a growing concern in emergency medicine and results in an increasing number of hospital admissions and fatalities. MDMA (3,4-methylenedioxymethamphetamine) and LSD (lysergic acid diethylamide) are two such drugs which have similar physical and psychological effects and are normally detected in blood and urine testing within 24–48 hours of ingestion. We present a case of a 22-year-old man who was found unconscious and unresponsive. History suggested the ingestion of illicit substances within the past 24 hours; however, urine and blood toxicology screening was negative. The patient was initially diagnosed with and treated for meningoencephalitis; however, CSF findings were negative. During the patient's recovery, he developed upper motor neurone neurological signs with pupillary dilatation. An MRI scan of the head was performed which revealed unusual features consistent with toxic leukoencephalopathy, most likely as a result of illicit substance intake. Further history was acquired confirming that the patient had ingested MDMA and LSD. The patient's presentation and course of admission is presented, with the clinical features of MDMA toxicity and the finding of toxic leukoencephalopathy reviewed.

Leptospirosis is a zoonotic bacterial infection with a reservoir in rodents and farm animals. It is a common disease in tropical countries but rare in the UK. The severe form (Weil's disease) caused by Leptospira is potentially fatal and includes liver failure, renal failure and haemorrhagic pneumonitis. Typical early symptoms of leptospirosis such as myalgia, headache, conjunctivitis and fever may be absent. Careful history-taking for contact with rodents or their excrement and/or farm animals should be performed to identify patients at risk for leptospirosis. Patients with pulmonary haemorrhage and kidney failure should be screened for leptospirosis. Liver failure may be attenuated or delayed by weeks. We describe a case which proved difficult to diagnose.

Among mechanically ventilated patients in adult general intensive care units, early tracheostomy insertion (within the first four days after admission) is not associated with an improvement in 30-day mortality.

Level of evidence: 1B