Journal of the Intensive Care Society

Dysphagia places a substantial burden on the critically ill, affecting 12%–84% of this cohort, and is independently associated with worse outcomes. Pharyngeal electrical stimulation (PES-treatment) is a novel dysphagia therapy with an emerging evidence base. This retrospective observational study describes our dysphagia service and reports the use of PES-treatment as a standard of care in recovering critically ill patients at a single-site tertiary UK hospital.

Patients admitted to Acute or Cardio-Thoracic adult intensive care units between 1st July 2017 and 30th June 2022 were routinely referred to Speech and Language Therapy (SLT) following tracheostomy, or suspected dysphonia/dysphagia. Clinical assessments and direct laryngeal visualisation using Fibreoptic Evaluation of Swallowing (FEES) were performed. Severe dysphagia was defined as Penetration-Aspiration Score of ⩾6 and patients were offered PES-treatment when staffing allowed.

Of 289 patients with severe dysphagia, 19 underwent a course of PES-treatment with the remaining patients receiving standard care. PES-treatment patients were significantly less likely to remain nil-by-mouth (11.1% vs 62.5%, Chi² p < 0.001) or to have an enteral feeding tube in situ at discharge from critical care (27.8% vs 62.5%, p = 0.006) than those receiving standard dysphagia care. Both groups demonstrated an improvement in Penetration-Aspiration Score at repeat FEES: PES-treatment mean difference −2.0 (p = 0.003); non-PES-treatment −1.68 (p < 0.001); (61% PES-treatment improved vs 40% non-PES-treatment, p = 0.09).

Our observations suggest that PES may be effective in the general critical care population. PES may offer new treatment options for patients and healthcare staff managing severe dysphagia and its significant consequences.

The handover and associated shift start checks by nurses of critical care patients are complex and prone to errors. However, which aspects lead to errors remains unknown. Fewer errors might occur in a structured approach. We hypothesized that specific gaze behavior during handover and shift start safety check correlates with error recognition.

In our observational eye tracking study, we analyzed gaze behavior of critical care nurses during handover and shift start safety check in a simulation room with built-in errors. Four areas of interest (AOI) were pre-defined (patient, respirator, prescriptions, monitor). The primary outcome were different gaze metrics (time to first fixation, revisits, first visual intake duration, average visual intake duration, dwell time) on AOIs. Parameters were analyzed by taking all errors in account, and by dividing them into minor and critical.

Forty-three participants were included. All participants committed at least a minor error (n = 43, 100%), at least one critical error occurred in 29 participants (67%). Taking all errors into account, longer time to first fixation and more revisits were associated with an increased risk of missing errors (Time to First Fixation: OR 1.099 (95% CI 1.023–1.191, p = 0.0002), Revisits: OR 1.080 (95% CI 1.025–1.143, p = 0.0055)).

Error detection during shift start safety check was associated with distinct gaze behavior. Nurses who recognized more errors had a shorter time to first fixation and less revisits. These gaze characteristics might correspond to a more structured approach. Further research is necessary, for example by implementing a checklist, to reduce errors in the future and improve patient safety.

Peripherally administered vasopressor infusions are used to support critically ill patients. The Intensive Care Society recently published guidelines supporting their use. Preliminary evidence suggests variability in peripheral vasopressor infusion use. We aimed to characterise current practice in the use of peripheral vasopressor infusions in the UK National Health Service and to capture the views of healthcare professionals caring for critically ill adult patients.

We conducted an online survey of healthcare professionals from December 2022 to March 2023. Our survey used Google Forms and was shared via email, X (formerly twitter), and mobile phone messaging within the UK. Health Research Authority approval was sought, and ethical approval was not required.

We received 227 responses and our survey showed variation in the use of peripherally administered vasopressor infusions in critically ill patients across UK National Health Service hospitals. About 87.7% of healthcare professionals initiated peripheral vasopressor infusions in their clinical role. Peripheral vasopressor use was limited to low dose, short durations of infusions, however, there was variability. Metaraminol was the most used peripheral vasopressor (90.3%). Only 22.5% of healthcare professionals used peripherally administered noradrenaline in practice. Our respondents agreed that equipoise exists.

Our survey found variability in the use of peripheral vasopressors and in care delivered to critically ill patients in the UK. Our survey shows there are ongoing concerns regarding safety, dosing ranges and durations of use. Future research is required to explore the optimal role that peripheral vasopressor infusions can play in the care of critically ill patients.

Critical care nurses (CCNs) face difficulties and stress when caring for patients with delirium, and the level of delirium-related stress may be related to gaps in their knowledge and skills.

This study aimed to assess the impact of a psychoeducational and relaxation program on reducing the stress of CCNs caring for patients with delirium in intensive care units (ICUs) in Taiz city, Yemen.

From June to the end of December 2022, a quasi-experimental study was conducted among 60 CCNs from two ICUs of Al-Thawra Hospital in Taiz. Demographic characteristics were collected using a pre-designed data collection sheet, and the levels of CCNs’ stress were measured using the Delirium Nursing Stress Scale (DNSS). To assess the impact of the developed psychoeducational and relaxation program, stress levels were measured before and after the program, as well as at a 3-month follow-up for long-term impact. The association of demographic characteristics with delirium-related stress was also studied. Data were then analyzed using appropriate statistical tests at a significance level of <0.05.

Before the program, the mean score of CCNs’ stress was 60.48 ± 9.51, corresponding to a moderate stress level of 86.7%. However, this score was significantly reduced to 30.98 ± 4.35 immediately after the program and was sustained at 33.13 ± 5.31 3 months after the program, corresponding to a mild stress level. The highest mean score of CCNs’ stress related to caring for patients with delirium was observed before the program for all causes of stress on the DNSS, being 4.95 ± 1.77 for the nursing environment, 9.37 ± 2.16 for relationships with peers, 14.40 ± 4.02 for knowledge about delirium, and 31.77 ± 5.78 for nursing practice and work. However, the mean stress scores related to all these causes showed a significant reduction after the program (2.85 ± 0.95, 4.70 ± 1.33, 7.20 ± 1.67, and 16.23 ± 2.80, respectively) and at the 3-month follow-up (3.15 ± 1.05, 4.95 ± 1.23, 7.67 ± 1.66 and 17.37 ± 3.57, respectively). On the other hand, the mean score of total stress for all DNSS items showed a significant reduction from 60.48 ± 9.51 before the program to 30.98 ± 4.35 after the program and 33.13 ± 5.31 at the 3-month follow-up. There were no statistically significant differences in the mean scores of delirium-related stress before and after the program, or at the 3-month follow-up for any of the demographic characteristics of CCNs.

Psychoeducational and relaxation programs have a positive impact on stress reduction in CCNs caring for patients with delirium, improving the standard of care provided to these patients. Regular assessment of CCNs for delirium-related stress and educating them to acquire knowledge and skills are recommended to reduce this stress when caring for delirious patients.

Fluid therapy is universally administered in the management of patients with sepsis, however excessive cumulative fluid balance has been shown to result in worse outcomes. Hyperoncotic albumin results in both lower fluid volumes and early cumulative fluid balance, and may reduce short-term mortality in patients with septic shock.

In this single centre, open label, feasibility trial; patients with early septic shock will be randomly allocated either 20% albumin for resuscitation and daily supplementation, versus buffered crystalloids alone for all fluid therapy. The intervention period will last 7 days, with follow up points at ICU and hospital discharge, and 90 days after randomisation.

Primary outcome measures including recruitment rate, intervention adherence, data completeness and safety will constitute objective evidence of feasibility, according to pre-specified thresholds. Secondary outcomes will include mortality and healthcare utilisation at 90 days, alongside other physiological and patient centred outcomes to inform the design of a future effectiveness trial.

This study will rigorously test the feasibility of conducting a future trial to test both the clinical and cost-effectiveness of hyperoncotic albumin in patients with early septic shock.

The formation of anastomoses between the pulmonary arteries and pulmonary veins, or the pulmonary and the bronchial circulation, is part of normal foetal lung development. They persist in approximately 30% of adults at rest, and open in almost all adults during exertion. Blood flowing through these anastomoses bypasses the alveolar surface and increases in such shunting can thus cause hypoxaemia. This is now known to contribute to the pathogenesis of hypoxaemia in COVID-19 disease. We here provide evidence to support a similar role in influenza A infection.

We describe a case of influenza A infection associated with severe hypoxaemia, poorly responsive to supplemental oxygen and which worsened following the application of continuous positive airway pressure (CPAP), despite the presence of a normal physical examination, chest radiograph and echocardiogram. This combination suggests a significant intrapulmonary (extra-alveolar) shunt as a cause of the severe hypoxaemia. The shunt fraction was estimated to be approximately 57%.

Intrapulmonary vascular shunts can contribute substantially to hypoxaemia in viral infection. Seeking to understand the pathogenesis of observed hypoxaemia can help guide respiratory therapy. Mechanistic research may suggest novel therapeutic targets which could assist in avoiding intubation and mechanical ventilatory support.