Journal of the Intensive Care Society

Personal protective equipment has important environmental impacts, assessing these impacts is therefore an important element of personal protective equipment design. We applied carbon footprinting methodology to Bubble-PAPR^™, a novel, part-reusable and part-recyclable powered air-purifying respirator, designed at our institution. Current guidance states that disposable respirator masks can be worn for 1-h in the United Kingdom, whilst the Bubble-PAPR^™ allows prolonged use.

Following a detailed use-case analysis, the carbon footprint of each component was estimated using a bottom-up (attributional) cradle-to-grave process-based analysis. Modelling considered the use of virgin or closed loop recycled polyvinyl chloride for the disposable hood element, and disposal via infectious or recycling waste streams to estimate a per-use carbon footprint.

The per-use carbon footprint with manufacture from virgin polyvinyl chloride and disposal via incineration is 0.805 kgCO₂e. With nine cycles of closed loop recycling and manufacture of the polyvinyl chloride hood (10 uses), the carbon footprint falls to an average of 0.570 kgCO₂e per use.

Carbon footprinting may contribute to the value proposition of this novel technology. We estimate that a single Bubble-PAPR^™ use has a higher carbon footprint than disposable respirator mask-based PPE. However, this is mitigated in circumstances when multiple disposable mask changes are required (e.g. prolonged use) and use may be justifiable when user comfort, visualisation and communication with patients and colleagues are essential.

Mechanically ventilated Intensive Care Unit (ICU) patients often require wrist restraints, contributing to immobility and agitation, over-sedation, and delirium. The Exersides® Refraint® (Healthy Design, LLC), a novel restraint alternative, may be safe and facilitate greater mobility than traditional restraints.

This National Institutes of Health Small Business Technology Transfer (STTR) Program Grant-funded single-site Phase I feasibility study evaluated Exersides® safety and feasibility in anticipation of a multi-site Phase II randomized controlled trial (RCT).

In two academic ICUs, mechanically ventilated adults ⩾25 years old who were non-comatose, required restraints and had an expected stay of ⩾2 days were enrolled to wear Exersides® and traditional wrist restraints for 4 h on day 1, in a randomized order, and in the reverse order on day 2. Main outcomes were Exersides® safety (i.e., patient/clinician lacerations/injuries), feasibility (i.e., ⩾90% of required data collected), and patient/family/clinician feedback.

Eight patients were enrolled; one no longer required restraints at initiation, yielding seven subjects (median [interquartile range (IQR)] age 65 [55, 70] years, 86% men). All seven wore Exersides®, averaging (SD) 2.5 (1.0) hours per session, with no safety events reported. Across restraint time periods, 92% and 100% of Richmond Agitation-Sedation Scale (RASS) and wrist actigraphy data, respectively, were collected. Feedback was positive (more movement and comfortable than traditional restraints) and constructive (bulky, intimidating to apply).

This pilot study provided key safety and feasibility data for a Phase II RCT evaluating Exersides® versus traditional wrist restraints. Feedback motivated minor device modifications before RCT initiation.

The importance of research and development in all aspects of healthcare is well acknowledged. Within critical care, national guidelines provide a limited number of standards and series of recommendations on Research and Development (R&D) activity. The aim of this study was to create a broader set of standards in support of R&D activity in critical care departments.

A modified Delphi study was undertaken across NHS Wales critical care units. Proposed standards were developed by a group of experts, which across three rounds, majority agreement was sought. Additional standards were added based on participant’s responses.

This study identified 49 standards for R&D activity within critical care units in NHS Wales. All these standards reached majority agreement, as determined by >70% of multi-disciplinary participants determine each standard as essential.

The results of this study will be utilised within Wales to inform wider service specification with regard workforce requirements, responsibilities, reporting and collaboration.

Frailty is common and is present in up to 30% of patients admitted to the ICU. We do not yet understand the true impact of ICU admission on this population, certainly in terms of longer-term outcomes.

Random selection of patients admitted to each general ICU within the SWARM network between October 1st 2012 and January 31st 2013. To be eligible, patients had to be over the age of 18 and admitted to the ICU with either a medical diagnosis or following emergency gastrointestinal/vascular surgery.

1888 patients were eligible for random selection. 560 patients were selected for the final analysis. Three hundred and eighteen patients had an estimated frailty score between 1 and 3 (classified as not frail, 56.8%), whilst 112 had a score of 4 (classified as vulnerable, 20%) and 130 patients had a score of between 5 and 7 (classified as frail, 23.2%). The median survival for patients with an estimated frailty score of four (vulnerable) was lower than those with an estimated score of 5 or greater (331.5 vs 594 days, p < 0.0001). One-year survival was 79% (75, 84), whilst 5-year survival was 69% (65, 75). Hazard ratios for ‘vulnerable’ and ‘frail’ sub-groups were estimated as 2.6 and 2.4 respectively.

There is significant evidence to suggest a strong causal association between frailty and survival after ICU admission. ‘Vulnerable’ status may well be associated with similar effect on long-term survival to that of ‘frailty’.

Continuous renal replacement therapy (CRRT) dose is usually fixed and primarily weight-based. Whilst this is safe, theoretically, underdosing or overdosing may occur in those requiring acute versus maintenance CRRT respectively. We have developed a dynamic dosing protocol for CRRT which individualises and updates dosing according to biochemistry. Here we describe the protocol and compare it to a fixed dose protocol to evaluate its safety and effectiveness.

We conducted a service evaluation of this novel protocol using data from consecutive non-COVID-19 admissions receiving CRRT within Barts Health NHS trust, United Kingdom (UK). Fifty admissions using the dynamic protocol were compared to historically collected data from 108 admissions who used the fixed protocol. Acute and maintenance CRRT subgroups were analysed.

For the dynamic protocol 49 patients were treated with 135 CRRT circuits. One patient had two admissions. Protocol compliance (compared in one ICU) was 76% (dynamic) vs 61% (fixed) (p < 0.05). For the dynamic versus fixed protocol, median CRRT lifespan censored for reasons other than clotting was: 56 h vs 58 h RCA (ns), 27 h versus 20 h heparin (ns) and 79 h versus 22 h no anticoagulation (p < 0.05). The dynamic vs fixed protocol average CRRT dose was: 30 ml/kg/h (14–57) vs 26 ml/kg/h (20–62) (p < 0.05). The dynamic protocol generated a similar rate of increase of bicarbonate in an acute phase (RCA: 0.2 mmol/l/h vs 0.21 mmol/l/h, ns) and maintained a more stable level in a maintenance phase (RCA: −0.01 mmol/l/h vs 0.07 mmol/l/h, p < 0.05).

Dynamic dosing for CRRT in this institution was safe and may lead to more tailored maintenance of biochemical homoeostasis.

Mechanical ventilation (MV) is a common and often live-saving intervention on the Intensive Care Unit (ICU). The optimisation of sedation to mechanical ventilation is fundamental, and inappropriate sedation has been associated with worse outcomes. This scoping review has been designed to answer the question ‘What is known about the use of ketamine as a continuous infusion to provide sedation in mechanically ventilated adults in the intensive care unit, and what are the gaps in the evidence?’

The protocol was designed using the PRISMA-ScR checklist and the JBI manual for evidence synthesis. Data were extracted and reviewed by a minimum of two reviewers.

Searches of electronic databases (PubMed, OVID, Scopus, Web of Science) produced 726 results; 45 citations were identified for further eligibility assessment, an additional five studies were identified through keyword searches, and 12 through searching reference lists. Of these 62 studies, 27 studies were included in the final review: 6 case reports/case series, 11 retrospective cohort/observational studies, 1 prospective cohort study, 9 prospective randomised studies.

We found a lack of high-quality well-designed studies investigating the use of continuous ketamine sedation on ICU. The available data suggests this intervention is safe and well tolerated, however this is of very low certainty given the poor quality of evidence.

Medical students receive relatively little exposure to intensive care medicine throughout their undergraduate training. The COVID-19 pandemic further hindered students’ exposure with the entrance to intensive care units (ICU) limited. To address the problem, this study explored the use of assisted reality technology to create a smart classroom in intensive care.

Six intensive care teaching sessions were live streamed to groups of medical students (n = 33) using wearable assisted reality glasses, and the results were pooled for analysis. Feedback from students and educators was collected using the evaluation of technology-enhanced learning materials (ETELM).

The response rate for the ETELM-learner and ETELM-educator perceptions was 100%. Students strongly agreed that the session was well organised, relevant and that the navigation of technology-based components was logical and efficient. Students strongly disagreed that their learning was negatively affected by technology issues. Educators reported some difficulties with balancing teaching delivery alongside the clinical demands of the ICU and some minor technological issues.

There is potential for smart classrooms to revolutionise intensive care education. The use of smart classrooms on intensive care using assisted reality technology was well received by students and educators. The main limitations included the cost of the technology and risk of technology issues. There is a significant role for smart classrooms to continue in the post-pandemic period as they provide an open and safe platform for students to explore intensive care medicine and ask questions that they may feel less able to raise in the busy clinical environment.