Journal of the Intensive Care Society

Defining research priorities in intensive care is key to determining appropriate allocation of funding. Several topics were identified from the 2014 James Lind Alliance priority setting exercise conducted with the Intensive Care Society. The James Lind Alliance process included significant (and vital) patient/public contribution, but excluded professionals without a bedside role. As a result it may have failed to identify potential early-stage translational research topics, which are more likely identified by medical and/or academic members of relevant specialist basic science groups. The objective of the present project was to complement the James Lind Alliance project by generating an updated list of research priorities by facilitating academic research input.

A survey was conducted by the National Institute for Health Research (NIHR) to identify the key research priorities from intensive care clinicians, including allied health professionals and academics, along with any evolving themes arising from translational research. Feasibility of all identified topics were then discussed and allocated to themes by a joint clinical academics/NIHR focus group.

The survey was completed by 94 intensive care clinicians (including subspecialists), academics and allied health professions. In total, 203 research questions were identified, with the top five themes focusing on: appropriate case selection (e.g. who and when to treat; 24%), ventilation (7%), sepsis (6%), delirium (5%) and rehabilitation (5%).

Utilising a methodology distinct from that employed by the James Lind Alliance process, from a broad spectrum of intensive care clinicians/scientists, enabled identification of a variety of priority research areas. These topics can now inform not only the investigator-led research agenda, but will also be considered in due course by the NIHR for potential future funding calls.

Physician's estimates of a patient's prognosis are an important component in shared decision-making. However, the variables influencing physician's judgments are not well understood. We aimed to determine which physician and patient factors are associated with physicians' predictions of critically ill patients' six-month mortality and the accuracy and confidence of these predictions.

Prospective cohort study evaluating physicians' predictions of six-month mortality. Using univariate and multivariable generalized estimating equations, we assessed the association between baseline physician and patient characteristics with predictions of six-month death, as well as accuracy and confidence of these predictions.

Our cohort was comprised 300 patients and 47 physicians. Physicians were asked to predict if patients would be alive or dead at six months and to report their confidence in these predictions. Physicians predicted that 99 (33%) patients would die. The key factors associated with both the direction and accuracy of prediction were older age of the patient, the presence of malignancy, being in a medical ICU, and higher APACHE III scores. The factors associated with lower confidence included older physician age, being in a medical ICU and higher APACHE III score.

Patient level factors are associated with predictions of mortality at six months. The accuracy and confidence of the predictions are associated with both physician and patients' factors. The influence of these factors should be considered when physicians reflect on how they make predictions for critically ill patients.

Intravenous fluid is important for resuscitation and maintenance of circuit flow in patients with extracorporeal membrane oxygenation, but fluid overload is widely recognized as detrimental in critically ill patients. This study aimed to evaluate the association between positive fluid balance and outcomes in adult patients treated with extracorporeal membrane oxygenation.

This was a retrospective observational study of a tertiary hospital from October 2010 to January 2018. Patients aged ≥18 years who received extracorporeal membrane oxygenation for ≥48 h were included. The fluid balance was determined as the difference between fluid intake and fluid output, and the cumulative fluid balance was calculated as the sum of these values on the preceding days. The primary outcome was hospital mortality.

Of the 123 included extracorporeal membrane oxygenation episodes, 79 were venovenous extracorporeal membrane oxygenation. The hospital mortality rate was 31.7%. Seventy-eight patients underwent continuous renal replacement therapy during their extracorporeal membrane oxygenation course. Non-survivors had a greater cumulative fluid balance (p≤0.001) and a lower cumulative fluid output (p = 0.006) than survivors on day 7. Fluid intake was not significantly different between survivors and non-survivors (p = 0.583). In the multivariate analysis, the cumulative fluid balance (per litre) on day 7, but not on day 3, was associated with increased hospital mortality (adjusted OR: 1.17, 95% CI: 1.06–1.29, p = 0.001).

In adult patients treated with extracorporeal membrane oxygenation, a higher positive cumulative fluid balance on day 7 was associated with increased hospital mortality. The association between positive fluid balance and mortality was mainly influenced by lower fluid output rather than an increase in fluid intake.

We sought a bespoke, stochastic model for our specific, and complex ICU to understand its organisational behaviour and how best to focus our resources in order to optimise our intensive care unit’s function.

Using 12 months of ICU data from 2017, we simulated different referral rates to find the threshold between occupancy and failed admissions and unsafe days. We also modelled the outcomes of four change options.

Ninety-two percent bed occupancy is our threshold between practical unit function and optimal resource use. All change options reduced occupancy, and less predictably unsafe days and failed admissions. They were ranked by magnitude and direction of change.

This approach goes one step further from past models by examining efficiency limits first, and then allowing change options to be quantitatively compared. The model can be adapted by any intensive care unit in order to predict optimal strategies for improving ICU efficiency.

Troponin elevation is central to the diagnosis of acute type 1 myocardial infarction. It is, however, elevated in a range of other conditions, including type 2 myocardial infarction, and this setting is increasingly associated with adverse clinical outcomes. Patients within intensive care frequently have at least one organ failure together with a range of co-morbidities. Interpretation of troponin assay results in this population is challenging. This clinical uncertainty is compounded by the introduction of ever more sensitive troponin assays.

The aims of this review are to (a) describe the currently available literature about the use of troponin assays in intensive care, (b) analyse the challenges presented by the introduction of increasingly sensitive troponin assays and (c) assess whether the role of troponin assays in intensive care may change in the future, dependent upon recent and ongoing research suggesting that they are predictive of outcome regardless of the underlying cause: the ‘never means nothing’ hypothesis.

A 60-year-old male presented to the emergency department with a history of confusion and collapse. Investigations revealed initial serum calcium of over 5 mmol/L. He subsequently developed widespread bilateral chest infiltrates with increasing oxygen requirements and an acute kidney injury. On day 9, continuous haemodiafiltration was commenced; however, hypercalcaemia proved resistant to maximal therapy. His initial parathyroid hormone (PTH) level measured 371 ng/L, and an ultrasound of his neck revealed a 2 × 2.5 cm parathyroid mass in the inferior neck. An acute parathyroidectomy was performed following which his chest infiltrates resolved and serum calcium levels returned to within normal range.

This case highlights primary hyperparathyroidism and the resulting hypercalcaemia as a sole cause for multi-organ failure in an otherwise well patient.