Journal of the Intensive Care Society

An autopsy is a medical procedure consisting of the thorough examination of the body and internal organs after death, to evaluate disease or injury and to determine the cause and manner of a person’s death. In the intensive care setting, autopsies are usually performed to determine the cause of death or further medical knowledge. Early evidence that showed an alarmingly high rate of medical misdiagnosis found at autopsy is being called into question; the role of the procedure itself is being scrutinised. Furthermore, there has been a marked decline in the number of autopsies being performed both in the UK and across Europe. We examine the role of autopsies in modern health care for critically ill patients.

This study aimed to investigate the effects of an incorrectly positioned tracheostomy tube on flow resistance. A laboratory-based model of the trachea was used with both cuffed and uncuffed tracheostomy tubes inserted to variable depths. With a constant metered flow through the model, the pressure for given depths of insertion was recorded. The model was then re-run to test the effect of different flow rates on the system. A total of 468 individual results were grouped and statistically analysed. They showed that both over- and under-insertion increase the pressure within the circuit and that a cuffed tracheostomy tube offers a degree of protection against this. These results were statistically significant with P < 0.05 demonstrating that incorrect positioning has a greater resistance to flow. These results provide an essential scientific basis for further work to assess the clinical significance of incorrect positioning as well as suggesting the need to monitor tube position.

Critical care in the United Kingdom is now well-established in terms of professional status, standards of clinical practice and training, and national audit through professional bodies and government representation. Research is fundamental to the further development and maturation of the specialty, to develop new therapies and technologies, more efficient and effective service organisation, and to improve patient and family experience and outcomes. Critical care research has expanded rapidly in the UK, and now has established organisations and infrastructure to share and develop ideas, through the UK Critical Care Research Forum and similar meetings. In September 2014, the Intensive Care Foundation and Critical Care Leadership Forum hosted a research colloquium to reflect, in part, on achievements, but more importantly plan for the future. With an invited list of participants the meeting explored firstly – the practical delivery of clinical research and secondly – the future financing landscape, from both academic funders’ and commercial developers’ perspectives. The following article summarises the important ‘take home’ messages from this meeting and suggests key issues for future strategy.

There are limited data on the incidence and management of acute faecal incontinence with diarrhoea in the ICU. The FIRST™ Observational Study was undertaken to obtain data on clinical practices used in the ICU for the management of acute faecal incontinence with diarrhoea in Germany, UK, Spain and Italy. ICU-hospitalised patients ≥18 years of age experiencing a second episode of acute faecal incontinence with diarrhoea in 24 h were recruited, and management practices of acute faecal incontinence with diarrhoea were recorded for up to 15 days. A total of 372 patients had complete data sets; the mean duration of study was 6.8 days. At baseline, 40% of patients experienced mild or moderate-to-severe skin excoriation, which increased to 63% in patients with acute faecal incontinence with diarrhoea lasting >15 days. At baseline, 27% of patients presented with a pressure ulcer, which increased to 37%, 45% and 49% at days 5, 10 and 15, respectively. Traditional methods (pads, sheets and tubes) were more commonly used compared to faecal management systems during days 1–4 (76% vs. 47% faecal management system), while the use of a faecal management system increased to 56% at days 5–9 and 61% at days 10–15. At baseline, only 26% of nurses were satisfied with traditional management methods compared to 69% with faecal management systems. For patients still experiencing acute faecal incontinence with diarrhoea after 15 days, 82% of nurses using a faecal management systems to manage acute faecal incontinence with diarrhoea were satisfied or very satisfied, compared to 37% using traditional methods. These results highlight that acute faecal incontinence with diarrhoea remains an important healthcare challenge in ICUs in Europe; skin breakdown and pressure ulcers remain common complications in patients with acute faecal incontinence with diarrhoea in the ICU.

Fever is common in critically ill patients and the cause is frequently not infection. Drug fevers occur in the intensive care and there are many pharmacological agents, by a variety of mechanisms, which increase body temperature beyond normal range. This article is a review of the common classes of drugs that can induce hyperthermia, highlighting the deleterious effects of a sustained high temperature and outlining available treatments.

Chest drains are common on intensive care units for a wide variety of clinical conditions. Despite this, there are no published data on their use within the intensive care unit and minimal published literature to guide decision making regarding the timing of their removal. Therefore, we undertook an audit to review our experience over one year, as to the degree of variability in when chest drains were removed. Using our electronic observation records, we assessed the length of stay of our chest drains against their functionality by whether they remained swinging (i.e. in connection with the pleural space) and whether they had a pathological fluid output (>150 mL/24 h). We found that our drains had a mean duration of 5.89 days, and that one-quarter remained in place for three days despite being non-functional. To conclude, we have devised a three-stage assessment (using the acronym I-T-U), to help guide an intensivist in the safe and timely removal of a chest drain.

The haemophagocytic syndrome is a unique disease process in which the dysregulation of the patient’s immune system leads to an inflammatory storm which rapidly ravages through multiple organ systems, generating life-threatening end-organ dysfunction. Since it usually mimics other conditions frequently encountered in the critical care population – most notably septic shock – its diagnosis is elusive and the condition remains under-recognized and under-reported. We present a concise review of the pathophysiology and clinical features of the heamophagocytic syndrome and discuss the main diagnostic and therapeutic issues relevant to the management of this condition in the critically ill patient. Increasing awareness about the haemophagocytic syndrome amongst intensive care physicians will facilitate earlier recognition and timely management.

In spite of decades of research, the acute respiratory distress syndrome (ARDS) continues to have an unacceptably high mortality and morbidity. Mesenchymal stromal cells (MSCs) present a promising candidate for the treatment of this condition and have demonstrated benefit in preclinical models. MSCs, which are a topic of growing interest in many inflammatory disorders, have already progressed to early phase clinical trials in ARDS. While a number of their mechanisms of effect have been elucidated, a better understanding of the complex actions of these cells may pave the way for MSC modifications, which might enable more effective translation into clinical practice.

The acute central nervous system infections meningitis and encephalitis commonly require management on intensive care units. The clinical features often overlap and in the acute phase–altered consciousness and seizures may also need to be managed. In April 2012, the first UK national guideline for the management of suspected viral encephalitis was published by the British Infection Association and Association of British Neurologists, and other key stakeholders, and included a simple management algorithm. The new guideline results from evidence demonstrating a number of common oversights in the standard management of suspected viral encephalitis in many settings. In combination with British Infection Association meningitis guidelines, evidence-based approaches now exist to facilitate the non-expert managing patients with suspected central nervous system infections. Here we bring together these guidelines and the supporting evidence applicable for intensivists into a single resource.

We report a case of a 75-year-old patient who presented with severe acute kidney injury due to Goodpasture’s syndrome. It is an uncommon autoimmune condition, requiring treatment with immunosuppressive drugs and plasma exchange. Prognosis depends largely on early diagnosis, so it is important to be aware of these rarer causes whenever anyone presents with acute kidney injury. She had two cardiac arrests in the emergency department, had a long stay in the intensive care unit and went on to develop pulmonary haemorrhage which improved with treatment. However, she developed end-stage renal failure for which she is on life-long dialysis.

We present the case of a 40-year-old woman diagnosed with Austrian syndrome, an association of endocarditis, meningitis and pneumonia caused by Streptococcus pneumonia. She had none of the risk factors previously described in the literature but on immunological assay was found to have low serum levels of mannose-binding lectin, a protein required for complement activation. The clinical manifestation and treatment of this condition are discussed, and we emphasize the importance of early recognition of cardiac involvement and prompt surgical management.