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Background: Circadian deregulation in patients treated in an intensive care unit (ICU) is commonplace and is associated with complications such as immune system disruption and delirium. The presence and nature of circadian rhythms in the vital signs recorded in the ICU are not well documented, nor is their generalisability across different ICU populations. This paper investigates the presence of circadian rhythms in the 24 h prior to discharge from an ICU of patients who subsequently recovered. We hypothesise that vital-sign circadian rhythms will be observable in this cohort of patients, that these circadian rhythms will resemble known behaviour in healthy individuals, and that these circadian rhythms will be generalisable across different populations of ICU patients. Methods: Circadian rhythms are investigated across several commonly measured vital signs: systolic blood pressure, heart rate, respiratory rate, and temperature. The data employed in this paper are from patients in the MIMIC-III (2001–2012), eICU-CRD (2014–2015), and PICRAM (2009–2015) databases, spanning 198,205 patients across 211 hospitals in the USA and the UK. Evaluation of circadian rhythms encompasses a comparison between the observed rhythm profiles and peak-nadir excursions with those found in the literature, as well as the assessment of the correlation in rhythm profiles between databases. Results: Circadian patterns in all four vital signs were found to conform to those reported for non-ICU cohorts. Additionally, all vital-sign circadian profiles were correlated between databases at the p = 0.05 level. The peak-nadir excursion in the observed rhythms was suppressed by a factor of 2–5 relative to results found in the literature for cohorts of young, healthy individuals. Conclusions: Across three different ICU datasets, systolic blood pressure, heart rate, respiratory rate, and temperature showed circadian variation in the 24 h prior to discharge from an ICU. However, the amplitude of these variations was markedly reduced in comparison to cohorts of young, healthy adults. The observed circadian variation correlated strongly between databases, suggesting there is a generalisable state of circadian behaviour in ICU patients during the 24 h prior to discharge from an ICU. This result has potential uses in monitoring patient recovery and early detection of complications such as delirium.

Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.

An amendment to this paper has been published and can be accessed via the original article.

An amendment to this paper has been published and can be accessed via the original article.

An amendment to this paper has been published and can be accessed via the original article.

An amendment to this paper has been published and can be accessed via the original article.

An amendment to this paper has been published and can be accessed via the original article.

Airway pressure release ventilation (APRV) is inverse ratio, pressure controlled, intermittent mandatory ventilation with unrestricted spontaneous breathing. It is based on the principle of open lung approach. It has many purported advantages over conventional ventilation, including alveolar recruitment, improved oxygenation, preservation of spontaneous breathing, improved hemodynamics, and potential lung-protective effects. It has many claimed disadvantages related to risks of volutrauma, increased work of breathing, and increased energy expenditure related to spontaneous breathing. APRV is used mainly as a rescue therapy for the difficult to oxygenate patients with acute respiratory distress syndrome (ARDS). There is confusion regarding this mode of ventilation, due to the different terminology used in the literature. APRV settings include the "P high," "T high," "P low," and "T low". Physicians and respiratory therapists should be aware of the different ways and the rationales for setting these variables on the ventilators. Also, they should be familiar with the differences between APRV, biphasic positive airway pressure (BIPAP), and other conventional and nonconventional modes of ventilation. There is no solid proof that APRV improves mortality; however, there are ongoing studies that may reveal further information about this mode of ventilation. This paper reviews the different methods proposed for APRV settings, and summarizes the different studies comparing APRV and BIPAP, and the potential benefits and pitfalls for APRV.

Current care guidelines recommend glucose control (GC) in critically ill patients. To achieve GC, many ICUs have implemented a (nurse-based) protocol on paper. However, such protocols are often complex, time-consuming, and can cause iatrogenic hypoglycaemia. Computerized glucose regulation protocols may improve patient safety, efficiency, and nurse compliance. Such computerized clinical decision support systems (CDSSs) use more complex logic to provide an insulin infusion rate based on previous blood glucose levels and other parameters. A computerized CDSS for glucose control has the potential to reduce overall workload, reduce the chance of human cognitive failure, and improve glucose control. Several computer-assisted glucose regulation programs have been published recently. In order of increasing complexity, the three main types of algorithms used are computerized flowcharts, Proportional-Integral-Derivative (PID), and Model Predictive Control (MPC). PID is essentially a closed-loop feedback system, whereas MPC models the behaviour of glucose and insulin in ICU patients. Although the best approach has not yet been determined, it should be noted that PID controllers are generally thought to be more robust than MPC systems. The computerized CDSSs that are most likely to emerge are those that are fully a part of the routine workflow, use patient-specific characteristics and apply variable sampling intervals.

Introduction Tight glycaemic control is an important issue in the management of intensive care unit (ICU) patients. The glycaemic goals described by Van Den Berghe and colleagues in their landmark study of intensive insulin therapy appear difficult to achieve in a real life ICU setting. Most clinicians and nurses are concerned about a potentially increased frequency of severe hypoglycaemic episodes with more stringent glycaemic control. One of the steps we took before we implemented a glucose regulation protocol was to review published trials employing insulin/ glucose algorithms in critically ill patients.Methods We conducted a search of the PubMed, Embase and Cochrane databases using the following terms: 'glucose', 'insulin', 'protocol', 'algorithm', 'nomogram', 'scheme', ' critically ill' and ' intensive care'. Our search was limited to clinical trials conducted in humans. The aim of the papers selected was required to be glycaemic control in critically ill patients; the blood glucose target was required to be 10 mmol/l or under ( or use of a protocol that resulted in a mean blood glucose = 10 mmol/l). The studies were categorized according to patient type, desired range of blood glucose values, method of insulin administration, frequency of blood glucose control, time taken to achieve the desired range for glucose, proportion of patients with glucose in the desired range, mean blood glucose and frequency of hypoglycaemic episodes.Results A total of twenty-four reports satisfied our inclusion criteria. Most recent studies ( nine) were conducted in an ICU; nine others were conducted in a perioperative setting and six were conducted in patients with acute myocardial infarction or stroke. Studies conducted before 2001 did not include normoglycaemia among their aims, which changed after publication of the study by Van Den Berghe and coworkers in 2001; glycaemic goals became tighter, with a target range between 4 and 8 mmol/l in most studies.Conclusion Studies using a dynamic scale protocol combining a tight glucose target and the last two blood glucose values to determine the insulin infusion rate yielded the best results in terms of glycaemic control and reported low frequencies of hypoglycaemic episodes.