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Communication difficulties and their effects on patients who are mechanically ventilated are commonly reported and well described. The possibility of restoring speech for patients has obvious benefits, not only for meeting patient’s immediate needs, but for helping them to re-engage in relationships and participate meaningfully in their recovery and rehabilitation. This opinion piece by a group of United Kingdom (UK) based Speech and Language Therapy experts working in critical care describes the various ways by which a patient’s own voice can be restored. Common barriers to using different techniques and potential solutions are explored. We therefore hope that this will encourage intensive care unit (ICU) multi-disciplinary teams to advocate and facilitate early verbal communication in these patients.

Intensive Care Unit staff deal with potentially traumatic cases throughout their careers. We designed and implemented a ‘Team Immediate Meet’ (TIM) tool, a communication aid designed to facilitate a two-minute ‘hot debrief’ after a critical event, provide the team with information about the normal reaction to such an event and signpost staff to strategies to help support their colleagues (and themselves). We describe our TIM tool awareness campaign, quality improvement project and subsequent feedback from staff who reported that the tool would be useful for navigating the aftermath of potentially traumatic events and could be transferable to other ICUs.

Background The Covid-19 pandemic has highlighted weaknesses in the National Health Service critical care provision including both capacity and infrastructure. Traditionally, healthcare workspaces have failed to fully incorporate Human-Centred Design principles resulting in environments that negatively affect the efficacy of task completion, patient safety and staff wellbeing. In the summer of 2020, we received funds for the urgent construction of a Covid-19 secure critical care facility. The aim of this project was to design a pandemic resilient facility centred around both staff and patient requirements and safety, within the available footprint. Methods We developed a simulation exercise, underpinned by Human-Centred Design principles, to evaluate intensive care designs through Build Mapping, Tasks Analysis and Qualitative data. Build Mapping involved taping out sections of the design and mocking up with equipment. Task Analysis and qualitative data were collected following task completion. Results 56 participants completed the build simulation exercise generating 141 design suggestions (69 task related, 56 patient and relative related, 16 staff related). Suggestions translated to 18 multilevel design improvements; five significant structural changes (Macro level) including wall moves and lift size change. Minor improvements were made at a Meso and Micro design level. Critical care design drivers identified included functional drivers (visibility, Covid-19 secure environment, workflow, and task efficiency) and behavioural drivers (learning and development, light, humanising intensive care and design consistency). Conclusion Success of clinical tasks, infection control, patient safety and staff/patient wellbeing are highly dependent on clinical environments. Primarily, we have improved clinical design by focusing on user requirements. Secondly, we developed a replicable approach to exploring healthcare build plans revealing significant design changes, that may have only been identified once built.

Background The decision to admit patients to the intensive care unit (ICU) is complex. Structuring the decision-making process may be beneficial to patients and decision-makers alike. The aim of this study was to investigate the feasibility and impact of a brief training intervention on ICU treatment escalation decisions using the Warwick model- a structured decision-making framework for treatment escalation decisions. Methods Treatment escalation decisions were assessed using Objective Structured Clinical Examination-style scenarios. Participants were ICU and anaesthetic registrars with experience of making ICU admission decisions. Participants completed one scenario, followed by training with the decision-making framework and subsequently a second scenario. Decision-making data was collected using checklists, note entries and post-scenario questionnaires. Results Twelve participants were enrolled. Brief decision-making training was successfully delivered during the normal ICU working day. Following training participants demonstrated greater evidence of balancing the burdens and benefits of treatment escalation. On visual analogue scales of 0–10, participants felt better trained to make treatment escalation decisions (4.9 vs 6.8, p = 0.017) and felt their decision-making was more structured (4.7 vs 8.1, p = 0.017). Overall, participants provided positive feedback and reported feeling more prepared for the task of making treatment escalation decisions. Conclusion Our findings suggest that a brief training intervention is a feasible way to improve the decision-making process by improving decision-making structure, reasoning and documentation. Training was implemented successfully, acceptable to participants and participants were able to apply their learning. Further studies of regional and national cohorts are needed to determine if training benefit is sustained and generalisable.

Aim In the United Kingdom (UK), 600 deaths per annum are attributable to drowning. Despite this there is scarce critical care data on drowning patients globally. We describe drowning cases admitted to critical care units with a focus on functional outcomes. Materials and Methods Medical records for critical care admissions following a drowning event were retrospectively reviewed across six hospitals in Southwest England for cases presenting in the period between 2009 and 2020. Data was collected according to the Utstein international consensus guidelines on drowning. Results Forty-nine patients were included, 36 males and 13 females, including seven children. Median submersion duration was 2.5 min 20 cases were in cardiac arrest when rescued. At discharge 22 patients had preserved functional status, 10 patients had a reduced functional status. 17 patients died in hospital. Conclusion Admission to critical care following drowning is uncommon and associated with high rates of mortality and poor functional outcomes. We find that 31% of those who survived a drowning event subsequently required an increased level of assistance with their activities of daily living.

A 48-year-old gentleman who had recently commenced chemotherapy for diffuse B-cell lymphoma was admitted to hospital with nausea and generalised weakness. He developed abdominal pain and oliguric acute kidney injury with multiple electrolyte derangements and was transferred to the intensive care unit (ICU). His condition deteriorated, requiring endotracheal intubation and renal replacement therapy (RRT). Tumour lysis syndrome (TLS) is a common and life-threatening complication of chemotherapy and represents an oncological emergency. TLS affects multiple organ systems and is best managed in the ICU with closer monitoring of fluid balance, serum electrolytes, cardiorespiratory and renal function. TLS patients may go on to require mechanical ventilation and RRT. TLS patients require input from a large multidisciplinary team of clinicians and allied health professionals.

Background Delayed gastric emptying (DGE) is a major cause of undernutrition that can be overcome using nasointestinal (NI) feeding, but tube placement often fails. We analyse which techniques enable successful NI tube placement. Methods Efficacy of tube technique was determined at each of six anatomical points: Nose, nasopharynx-oesophagus, stomach-upper and -lower, duodenum part-1 and intestine. Results In 913 first NI tube placements, significant associations with tube advancement were found in the pharynx (head tilt, jaw thrust, laryngoscopy), stomach_upper (air insufflation, 10 cm or 20–30 cm flexible tube tip ± reverse Seldinger manoeuvre), stomach_lower (air insufflation, possibly flexible tip and wire stiffener) and duodenum part-1 and beyond part-2 (flexible tip and combinations of micro-advance, slack removal, wire stiffener or prokinetic drugs). Conclusion This is the first study to show what techniques are associated with tube advancement and the alimentary tract level they are specific to.

Purpose Prolonged bed rest and immobility in the intensive care units (ICU) increase the risk of ICU-acquired weakness (ICUAW) and other complications. Mobilisation has been shown to improve patient outcomes but may be limited by the perceived barriers of healthcare professionals to mobilisation. The Patient Mobilisation Attitudes and Beliefs Survey for the ICU (PMABS-ICU) was adapted to assess perceived barriers to mobility in the Singapore context (PMABS-ICU-SG). Methods The 26-item PMABS-ICU-SG was disseminated to doctors, nurses, physiotherapists, and respiratory therapists working in ICU of various hospitals across Singapore. Overall and subscale (knowledge, attitude, and behaviour) scores were obtained and compared with the clinical roles, years of work experience, and type of ICU of the survey respondents. Results A total of 86 responses were received. Of these, 37.2% (32/86) were physiotherapists, 27.9% (24/86) were respiratory therapists, 24.4% (21/86) were nurses and 10.5% (9/86) were doctors. Physiotherapists had significantly lower mean barrier scores in overall and all subscales compared to nurses (p < 0.001), respiratory therapists (p < 0.001), and doctors (p = 0.001). A poor correlation (r = 0.079, p < 0.05) was found between years of experience and the overall barrier score. There was no statistically significant difference in the overall barriers score between types of ICU (χ2(2) = 4.720, p = 0.317). Conclusion In Singapore, physiotherapists had significantly lower perceived barriers to mobilisation compared to the other three professions. Years of experience and type of ICU had no significance in relation to barriers to mobilisation.

Background This study aims to identify any effect of frailty in altering the risk of death or poor outcome already associated with receipt of organ support on ICU. It also aims to assess the performance of mortality prediction models in frail patients. Methods All admissions to a single ICU over 1-year were prospectively allocated a Clinical Frailty Score (CFS). Logistic regression analysis was used to investigate the effect of frailty on death or poor outcome (death/discharge to a medical facility). Logistic regression analysis, area under the Receiver Operator Curve (AUROC) and Brier scores were used to investigate the ability of two mortality prediction models, ICNARC and APACHE II, to predict mortality in frail patients. Results Of 849 patients, 700 (82%) patients were not frail, and 149 (18%) were frail. Frailty was associated with a stepwise increase in the odds of death or poor outcome (OR for each point rise of CFS = 1.23 ([1.03–1.47]; p = .024) and 1.32 ([1.17–1.48]; p = Conclusions Frailty was associated with increased odds of death and poor outcome, but did not modify the risk already associated with organ support. Inclusion of frailty improved mortality prediction models.

Purpose The use of coercion, in a clinical context as imposing a measure against a patient’s opposition or declared will, can occur in various forms in intensive care units (ICU). One prime example of a formal coercive measure in the ICU is the use of restraints, which are applied for patients’ own safety. Through a database search, we sought to evaluate patient experiences related to coercive measures. Results For this scoping review, clinical databases were searched for qualitative studies. A total of nine were identified that fulfilled the inclusion and the CASP criteria. Common themes emerging from the studies on patient experiences included communication issues, delirium, and emotional reactions. Statements from patients revealed feelings of compromised autonomy and dignity that came with a loss of control. Physical restraints were only one concrete manifestation of formal coercion as perceived by patients in the ICU setting. Conclusion There are few qualitative studies focusing on patient experiences of formal coercive measures in the ICU. In addition to the experience of restricted physical movement, the perception of loss of control, loss of dignity, and loss of autonomy suggests that restraining measures are just one element in a setting that may be perceived as informal coercion.

Critical illness-related cardiac arrest (CIRCA) as a distinct entity is not well described epidemiologically. There is currently a knowledge gap regarding how many occur in the UK or the impact on patient outcome. The CIRCA study is a prospective multi-centre observational cohort study of patients in the United Kingdom experiencing a cardiac arrest while in a Critical Care Unit embedded in the Case Mix Programme and National Cardiac Arrest Audit. The duration of data collection is 12 months, with surviving patients and family members receiving questionnaire follow-up at 90 days, 180 days and 12 months. This paper describes the protocol for the CIRCA study which received favourable ethical opinion from South Central – Berkshire Research Ethics Committee and approval from the Health Research Authority. Study registration is on clinicaltrials.gov (NCT04219384).

Background: One of the main concerns in critical care units is the development of humanistic approaches. In this regard, recognizing the factors affecting humanistic nursing can contribute to humanizing nursing care in these units. Objective: The objective was to recognize the influential factors of humanistic nursing in critical care units. Research design: This qualitative study was carried out using a phenomenology method. Thirty-nine in-depth unstructured interviews were performed. The data were analyzed using the phenomenological nursology approach. To guarantee trustworthiness, prolonged engagement, member check, triangulation of resources, and maximum variation sampling were used. Participants and research context: Purposeful sampling was employed to select 10 nurses, 8 patients, and 4 patient’s relatives from the intensive care unit and critical care unit departments. Ethical consideration: This study was approved by the ethics committee of Lorestan University of Medical Sciences with the code of LUMS.REC.1395.121. Finding: The participants’ experiences were reflected in the following three main concepts: (a) moral, educational, and existential nature of the two humans involved in the interaction; (b) maintenance of the nurses’ dignity; and (c) interactions in the cultural and social context. Discussion: The nurse and patient, organizational environment, and society give rise to a set of intertwined characteristics which influence the realization of humanistic nursing. By affecting the nurses’ educational background and maintaining their dignity, the atmosphere of the hospital and cultural readiness of the society pave the way for delivering the humanistic care.

Context Increasing dissatisfaction with existing methods of assessment in the workplace alongside a national drive towards outcomes-based postgraduate curricula led to a recent overhaul of the way Intensive Care Medicine (ICM) trainees are assessed in the United Kingdom. Programmatic assessment methodology was utilised; the existing ‘tick-box’ approach using workplace-based assessment to demonstrate competencies was de-emphasised and the expertise of trainers used to assess capability relating to fewer, high-level outcomes related to distinct areas of specialist practice. Methods A thematic analysis was undertaken investigating attitudes from 125 key stakeholders, including trainees and trainers, towards the new assessment strategy in relation to impact on assessment burden and acceptability. Results This qualitative study suggests increased satisfaction with the transition to an outcomes-based model with capability judged by educational supervisors. However, reflecting frustration relating to current assessment in the workplace, participants felt assessment burden has been significantly reduced. The approach taken was felt to be an improved method for assessing professional practice; there was enthusiasm for this change. However, this research highlights trainee and trainer anxiety regarding how to ‘pass’ these expert judgement decisions of capability in the real world. Additionally, concerns relating to the impact on subgroups of trainees due to the potential influence of implicit biases on the resultant fewer but ‘higher stakes’ interrogative judgements became apparent. Conclusion The move further towards a constructivist paradigm in workplace assessment in ICM reduces assessment burden yet can provoke anxiety amongst trainees and trainers requiring considered implementation. Furthermore, the perception of potential for bias in global judgements of performance requires further exploration.

Heatstroke represents the most severe end of the heat illness spectrum, and is increasingly seen in those undergoing exercise or exertion (‘exertional heatstroke’) and those exposed to high ambient temperatures, for example in heatwaves (‘classical heatstroke’). Both forms may be associated with significant thermal injury, leading to organ dysfunction and the need for admission to an intensive care unit. The process may be exacerbated by translocation of bacteria or endotoxin through an intestinal wall rendered more permeable by the hyperthermia. This narrative review highlights the importance of early diagnosis, rapid cooling and effective management of complications. It discusses the incidence, clinical features and treatment of heatstroke, and discusses the possible role of intestinal permeability and advances in follow-up and recovery of this condition. Optimum treatment involves an integrated input from prehospital, emergency department and critical care teams, along with follow-up by rehabilitation teams and, if appropriate, sports or clinical physiologists.

A 76-year-old lady was found on the floor following a fall at home. She was uninjured, but unable to get up, and had been lying on the floor for roughly 18 hours before her son arrived. She had been unwell for the past 3 days with a cough and shortness of breath. She had a past medical history of diabetes, hypertension, hypercholesterolaemia and atrial fibrillation (AF). On examination, she was alert but distressed, clinically dehydrated, febrile and tachycardic. She was treated for community acquired pneumonia with co-amoxiclav and was fluid resuscitated with Hartmann’s solution. Her hyperkalaemia was treated with 50 mL of 50% glucose containing 10 units of rapid-acting insulin. Her creatinine kinase (CK) on admission was 200,000, and she had an acute kidney injury (AKI). Urine dipstick was positive for blood. However, her renal function continued to deteriorate over the succeeding 48 h, when she required renal replacement therapy (RRT) due to fluid overload and anuria.

Background:Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses’ sources of distress is important when planning interventions to support them.Purpose:To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic.Design:Qualitative descriptive component within a larger mixed-methods study.Participants and research context:Participants were invited to write down their experiences of a critical incident, which distressed them when providing nursing care. Thematic analysis was used to analyze the data.Ethical considerations:The study was approved by the ethics committee at the researchers’ university in eastern Canada.Results:A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families’ grief, (3) our safety, and (4) futility of care. Many nurses’ stories also focused on the organizational preparedness of their institutions and concerns over their own safety.Discussion:Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed.Conclusion:Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses’ well-being.

Introduction Point-of-care ultrasound (POCUS) has an established role in the management of the critically ill. Information and experience of its use in those with COVID-19 disease is still evolving. We undertook a review of cardiac and thoracic ultrasound examinations in patients with COVID-19 on the intensive care unit (ICU). Our aim was to report key findings and their impact on patient management. Methods A retrospective evaluation of critically ill patients with COVID-19 was undertaken in three adult ICUs, who received point-of-care cardiac and/or thoracic ultrasound during the 2019–2020 COVID-19 pandemic. We recorded baseline demographic data, principal findings, change in clinical management and outcome data. Results A total of 55 transthoracic echocardiographic examinations scans were performed on 35 patients. 35/55 (64%) echocardiograms identified an abnormality, most commonly a dilated or impaired right ventricle (RV) and 39/55 (70%) scans resulted in a change in management. Nine patients (26%) were found to have pulmonary arterial thrombosis on CTPA or post-mortem. More than 50% of these patients showed evidence of right ventricular dilatation or impairment. Of the patients who were known to have pulmonary arterial thrombosis and died, 83% had evidence of right ventricular dilatation or impairment. 32 thoracic ultrasound scans were performed on 23 patients. Lung sliding and pleural thickening were present bilaterally in all studies. Multiple B-lines were present in all studies, and sub-pleural consolidation was present bilaterally in 72%. Conclusion POCUS is able to provide useful and clinically relevant information in those critically ill with COVID-19 infection, resulting in change in management in a high proportion of patients. Common findings in this group are RV dysfunction, multiple B-lines and sub-pleural consolidation.

Cases of thromboses at unusual sites with thrombocytopenia have been reported following vaccination against Sars-CoV-2. This new syndrome, christened vaccine-induced thrombotic thrombocytopenia (VITT), mainly results in venous thromboses. We report the case of a young woman with a right middle cerebral artery stroke following vaccination with ChAdOx1 nCoV-19. A diagnosis of VITT was made and platelet counts began to recover shortly after commencing treatment with argatroban, intravenous immunoglobulins and corticosteroids. On day 6 following admission, the patient deteriorated neurologically and decision made to proceed with decompressive hemicraniectomy. There were no perioperative complications and anticoagulation with argatroban was reinitiated on the first postoperative day. VITT is a rare condition resembling auto-immune heparin-induced thrombocytopenia. All critical care staff should be aware of the rare link between vaccination against SARS-CoV-2 and VITT and the need to rapidly commence both anticoagulation, using heparin alternatives, and immunomodulation.

A thirty-year-old pregnant woman was admitted to hospital with headache and gastrointestinal discomfort. She developed peripheral oedema and had an emergency caesarean section following an episode of tonic-clonic seizures. Her delivery was further complicated by postpartum haemorrhage and she was admitted to the Intensive Care Unit (ICU) for further resuscitation and seizure control which required infusions of magnesium and multiple anticonvulsants. Despite haemodynamic optimisation she developed an acute kidney injury with evidence of liver damage, thrombocytopenia and haemolysis. Haemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome, a multisystem disease of advanced pregnancy which overlaps with pre-eclampsia, was diagnosed. HELLP syndrome is associated with a range of complications which may require critical care support, including placental abruption and foetal loss, acute kidney injury, microangiopathic haemolytic anaemia, acute liver failure and liver capsule rupture. Definitive treatment of HELLP is delivery of the fetus and in its most severe forms requires admission to the ICU for multiorgan support. Therapeutic strategies in ICU are mainly supportive and include blood pressure control, meticulous fluid balance and possibly escalation to renal replacement therapy, mechanical ventilation, neuroprotection, seizure control, and management of liver failure-related complications. Multidisciplinary input is essential for optimal treatment.

Background Intensive care units are significantly louder than WHO guidelines recommend. Patients are disturbed by activities around them and frequently report disrupted sleep. This can lead to slower recovery and long-term health problems. Environmental sound levels are usually reported as LAeq24, a single daily value that reflects mean sound levels over the previous 24-h period. This may not be the most appropriate measure for intensive care units (ICUs) and other similar areas. Humans experience sound in context, and disturbance will vary according to both the individual and acoustic features of the ambient sounds. Loudness is one of a number of measures that approximate the human perception of sound, taking into account tone, duration, and frequency, as well as volume. Typically sounds with higher frequencies, such as alarms, are perceived as louder and more disturbing. Methods Sound level data were collected from a single NHS Trust hospital general adult intensive care unit between October 2016 and May 2018. Summary data (mean sound levels (LAeq) and corresponding Zwicker calculated loudness values) were subsequently analysed by minute, hour, and day. Results The overall mean LAeq24 across the study duration was 47.4 dBA. This varied by microphone location. We identified a clear pattern to sound level fluctuations across the 24-h period. Weekends were significantly quieter than weekdays in statistical terms but this reduction of 0.2 dB is not detectable by human hearing. Peak loudness values over 90 dB were recorded every hour. Conclusions Perception of sound is sensitive to the environment and individual characteristics and sound levels in the ICU are location specific. This has implications for routine environmental monitoring practices. Peak loudness values are consistently between 90 and 100 dB. These may be driven by alarms and other sudden high-frequency sounds, leading to more disturbance than LAeq24 sound levels suggest. Addressing sounds with high loudness values may improve the ICU environment more than an overall reduction in the 24-h mean decibel value.

Blood for coagulation analysis can be sampled from the arterial or venous system in intensive care units (ICU). The determination of clot microstructure and strength by fractal analysis (d f) gives valuable information in a range of vascular haemostatic disease and sepsis. We aimed to determine if d f could be measured equally and comparatively in arterial or venous blood, and 45 critically ill patients in an ICU were recruited. d f was found to be readily measured in arterial blood with results comparable to those in venous blood and that add value of d f as a potential marker of haemostasis in these patients.

Background Whilst the management of Coronavirus disease-2019 (COVID-19) has evolved in response to the emerging data, treating such patients remains a challenge, and many treatments lack robust clinical evidence. We conducted a survey to evaluate Intensive Care Unit (ICU) management of COVID-19 patients with acute hypoxic respiratory failure and compared the results with data from a similar survey focusing on Acute Respiratory Distress Syndrome (ARDS) that was conducted in 2013. Methods The questionnaire was refined from a previous survey of ARDS-related clinical practice using an online electronic survey engine (Survey Monkey®) and all UK intensivists were encouraged to participate. The survey was conducted between 16/05/2020 and 17/06/2020. Results There were 137 responses from 89 UK centres. Non-invasive ventilation was commonly used in the form of CPAP. The primary ventilation strategy was the ARDSnet protocol, with 63% deviating from its PEEP recommendations. Similar to our previous ARDS survey, most allowed permissive targets for hypoxia (94%), hypercapnia (55%) and pH (94%). The routine use of antibiotics was common, and corticosteroids were frequently used, usually in the context of a clinical trial (45%). Late tracheostomy (>7 days) was preferred (92%). Routine follow-up was offered by 66% with few centres providing routine dedicated rehabilitation programmes following discharge. Compared to the ARDS survey, there is an increased use of neuromuscular agents, APRV ventilation and improved provision of rehabilitation services. Conclusions Similar to our previous ARDS survey, this survey highlights variations in the management strategies used for patients with acute hypoxic respiratory failure due to COVID-19.

Background Despite oxygen being the commonest drug administered to critically ill patients we do not know which oxygen saturation (SpO2) target results in optimal survival outcomes in those receiving mechanical ventilation. We therefore conducted a feasibility randomised controlled trial in the United Kingdom (UK) to assess whether it would be possible to host a larger national multi-centre trial to evaluate oxygenation targets in mechanically ventilated patients. Methods We set out to recruit 60 participants across two sites into a trial in which they were randomised to receive conservative oxygenation (SpO2 88–92%) or usual care (control – SpO2 ≥96%). The primary outcome was feasibility; factors related to safety and clinical outcomes were also assessed. Results A total of 34 patients were recruited into the study until it was stopped due to time constraints. A number of key barriers to success were identified during the course of the study. The conservative oxygenation intervention was feasible and appeared to be safe in this small patient cohort and it achieved wide separation of the median time-weighted average (IQR) SpO2 at 91% (90–92%) in conservative oxygenation group versus 97% (96–97%) in control group. Conclusion Whilst conservative oxygenation was a feasible and safe intervention which achieved clear group separation in oxygenation levels, the model used in this trial will require alterations to improve future participant recruitment rates in the UK.

The internet is increasingly used to propagate medical education, debate, and even disinformation. Therefore, this primer aims to help acute care medical professionals, as well as the public. This is because we all need to be able to critically appraise digital products, appraise content producers, and reflect upon our own on-line presence. This article discusses the challenges and opportunities associated with online medical resources. We then review Free Open Access Medical Education (FOAMed) and the key tools used to assess the trustworthiness of on-line medical products. Specifically, after discussing the pros and cons of traditional academic quality metrics, we compare and contrast the Social Media Index, the ALiEM AIR score, the Revised METRIQ Score, and gestalt. We also discuss internet search engines, peer review, and the important message behind the seemingly tongue-in-cheek Kardashian Index. Hopefully, this primer bolsters basic digital literacy and helps trainees, practitioners, and the public locate useful and reliable on-line resources. Importantly, we highlight the continued importance of traditional academic medicine and primary source publications.

Aim: To describe the protocol for a multi-centre randomised controlled trial to determine whether treatment protocols monitoring daily CRP (C-reactive protein) or PCT (procalcitonin) safely allow a reduction in duration of antibiotic therapy in hospitalised adult patients with sepsis. Design: Multicentre three-arm randomised controlled trial. Setting: UK NHS hospitals. Target population: Hospitalised critically ill adults who have been commenced on intravenous antibiotics for sepsis. Health technology: Three protocols for guiding antibiotic discontinuation will be compared: (a) standard care; (b) standard care + daily CRP monitoring; (c) standard care + daily PCT monitoring. Standard care will be based on routine sepsis management and antibiotic stewardship. Measurement of outcomes and costs. Outcomes will be assessed to 28 days. The primary outcomes are total duration of antibiotics and safety outcome of all-cause mortality. Secondary outcomes include: escalation of care/re-admission; infection re-lapse/recurrence; antibiotic dose; length and level of critical care stay and length of hospital stay. Ninety-day all-cause mortality rates will also be collected. An assessment of cost effectiveness will be performed. Conclusion: In the setting of routine NHS care, if this trial finds that a treatment protocol based on monitoring CRP or PCT safely allows a reduction in duration of antibiotic therapy, and is cost effective, then this has the potential to change clinical practice for critically ill patients with sepsis. Moreover, if a biomarker-guided protocol is not found to be effective, then it will be important to avoid its use in sepsis and prevent ineffective technology becoming widely adopted in clinical practice.

Background: COVID-19 has fundamentally changed all fields of health care. Intensive care nurses have been at the forefront of the pandemic facing the massive impact of the disease, both professionally and personally. This study investigated nurses’ experiences of caring for isolated COVID-19 positive patients in the intensive care department during the first wave of the COVID-19 pandemic. The study investigated how isolation affected the nurses themselves, how they related with their patients, and how isolation affected patient care in general. Methods: The study was performed at a 20-bed university hospital intensive care department in Copenhagen, Denmark. COVID-19 positive patients were isolated or cohort isolated. A dedicated nurse cared for each isolated patient and wore full personal protective equipment. The study is based on in-depth phenomenological interviews with intensive care nurses conducted in summer 2020. The interviews were structured according to the principles of “Phenomenologically Grounded Qualitative Research.” The data included observations from within the isolated patient rooms. Findings: Six intensive care nurses participated in the study. The analysis documented following themes consistently reported by all nurses: (1) a general sense of uncanniness, (2) intense feelings of confinement and co-isolation, and (3) heightened senses of bodily objectification, including how nurses’ experienced their patients and also themselves. Conclusion: This is the first Scandinavian phenomenological study to focus on mapping the experiences of intensive care nurses during the extreme circumstances of the first wave of the COVID-19 pandemic. Further studies may explore long-term effects, such as psychiatric morbidity or psychological functioning in these individuals.

The aim of this study was to assess whether high sensitivity troponin (hs-cTnI) is associated with 1 year mortality in critical care (CC). One year mortality data were obtained from NHS Digital for a consecutive cohort of patients admitted to general CC unit (GCCU) and neuroscience CC unit (NCCU) who had hs-cTnI tests performed throughout their CC admission, regardless of whether the test was clinically indicated. Cox proportional hazards were used to estimate the risk of 1-year mortality. A landmark analysis was undertaken to assess whether any relationship at 1 year was driven by mortality within the first 30 days. A total of 1033 consecutive patients were included. At 1 year 254 (24.6%) patients had died. The admission log(10)hs-cTnI concentration in the entire cohort (HR 1.35 (95% CI 1.05–1.75) p = 0.009 with a bootstrap of 1000 samples) was independently associated with 1 year mortality. On landmark analysis the association with 1 year mortality was driven by 30 day mortality. These results indicate that admission hs-cTnI concentration is independently associated with 1 year mortality in CC and this relationship may be driven by differences in mortality at 30 days.

Aortic dissections are associated with significant mortality and morbidity, with rapid treatment paramount. They are caused by a tear in the intimal lining of the aorta that extends into the media of the wall. Blood flow through this tear leads to the formation of a false passage bordered by the inner and outer layers of the media. Their diagnosis is challenging, with most deaths caused by aortic dissection diagnosed at post-mortem. Aortic dissections are classified by location and chronicity, with management strategies depending on the nature of the dissection. The Stanford method splits aortic dissections into type A and B, with type A dissections involving the ascending aorta. De Bakey classifies dissections into I, II or III depending on their origin and involvement and degree of extension. The key to diagnosis is early suspicion, appropriate imaging and rapid initiation of treatment. Treatment focuses on initial resuscitation, transfer (if possible and required) to a suitable specialist centre, strict blood pressure and heart rate control and potentially surgical intervention depending on the type and complexity of the dissection. Effective post-operative care is extremely important, with awareness of potential post-operative complications and a multi-disciplinary rehabilitation approach required. In this review article we will discuss the aetiology and classifications of aortic dissection, their diagnosis and treatment principles relevant to critical care. Critical care clinicians play a key part in all these steps, from diagnosis through to post-operative care, and thus a thorough understanding is vital.

We present a single centre study describing the effect of awake prone position (PP) on oxygenation and clinical outcomes in spontaneously breathing patients with novel coronavirus disease (COVID-19). Between 1st March and 30th April 2020, forty eight of 138 patients managed outside of the critical care unit with facemask oxygen, high flow nasal oxygen (HFNO) or continuous positive airway pressure (CPAP), underwent PP. Prone position was associated with significant improvement in oxygenation, lower ICU admission, tracheal intubation, and shorter ICU length of stay. Lack of response to PP may be an indicator of treatment failure, requiring early escalation.

A 70 year old man, who had recently travelled in rural Iraq, presented with fevers, rigors, and developed multiorgan failure. An extensive range of diagnostic tests was undertaken in an attempt to identify the cause. He was treated with multi-organ support and a number of antibiotics. Critical illness in the returning traveller presents a number of challenges on the ICU: obtaining adequate history, the potentially broad differential diagnosis, the requirement for numerous and sometimes specialised investigations and risks of infection transmission to staff and other patients. Travellers are more often elderly, more likely to have comorbidities and immunosuppression whilst global disease patterns are changing. Particular consideration should be given to unusual infections and venous thromboembolic disease from prolonged immobility whilst in transit, alongside more commonly encountered diseases. Antimicrobial resistance may be encountered and appropriate infection control is essential for the protection of patients, staff and others. Specialist support is available in the UK via the Imported Fever Service, especially for High Consequence Infectious Diseases. Consideration of non-infectious causes of fever and critical illness in returning travellers is also warranted. Crucially, a multidisciplinary team approach with thorough information gathering, repeated clinical review and judicious use of investigations are essential for optimal patient care.

Background Many Intensive Care Unit (ICU) survivors suffer from a multi- system disability, termed the post-intensive care syndrome. There is no current national coordination of either rehabilitation pathways or related data collection for them. In the last year, the need for tools to systematically identify the multidisciplinary rehabilitation needs of severely affected COVID-19 survivors has become clear. Such tools offer the opportunity to improve rehabilitation for all critical illness survivors through provision of a personalised Rehabilitation Prescription (RP). The initial development and secondary refinement of such an assessment and data tools is described in the linked paper. We report here the clinical and workforce data that was generated as a result. Methods Prospective service evaluation of 26 acute hospitals in England using the Post-ICU Presentation Screen (PICUPS) tool and the RP. The PICUPS tool comprised items in domains of a) Medical and essential care, b) Breathing and nutrition; c) Physical movement and d) Communication, cognition and behaviour. Results No difference was seen in total PICUPS scores between patients with or without COVID-19 (77 (IQR 60-92) vs. 84 (IQR 68-97); Mann-Whitney z = −1.46, p = 0.144. A network analysis demonstrated that requirements for physiotherapy, occupational therapy, speech and language therapy, dietetics and clinical psychology were closely related and unaffected by COVID-19 infection status. A greater proportion of COVID-19 patients were referred for inpatient rehabilitation (13% vs. 7%) and community-based rehabilitation (36% vs.15%). The RP informed by the PICUPS tool generally specified a greater need for multi-professional input when compared to rehabilitation plans instituted. Conclusions The PICUPS tool is feasible to implement as a screening mechanism for post-intensive care syndrome. No differences are seen in the rehabilitation needs of patients with and without COVID-19 infection. The RP could be the vehicle that drives the professional interventions across the transitions from acute to community care. No single discipline dominates the rehabilitation requirements of these patients, reinforcing the need for a personalised RP for critical illness survivors.

Occupational stress is a major health problem among nurses. Critical care nurses appear to experience more stress at work compared to others. Stress is associated with multiple system disorders, hormonal, and immunological disturbances, and genetic effects. The aim of our study was the detection of health effects of work-related stress and to investigate the link between stress and immune response, alterations of hormones, and expression of micro-RNA (miRNA) among critical care nurses. An exposed 80 critical care nurses matched to 80 controls were involved in our study. Full history, psychological assessment using the General Health Questionnaire (GHQ12) and a complete clinical examination were done for both groups. Serum interleukin (IL)-6, IL-10, luteinizing hormone (LH), follicle-stimulating hormone, thyroid-stimulating hormone (TSH), free triiodothyronine, and free thyroxine (FT4) were measured by enzyme-linked immunosorbent assay, micro-RNA26, and 142 extractions. The exposed group had a mean age of 41 ± 10 years old and mean work duration of 22 ± 9.7 years, matched to 80 controls. The exposed group (32.5%) was associated with severe psychological distress (GHQ scores > 20) compared to only 5% among controls. In addition, the exposed group had a significantly higher level of miRNA 26, miRNA 142, TSH, LH, and IL-6 when compared to the control group. However, there a significantly lower level of FT4 among the exposed group compared to the control group, there were no statistically significant differences between the studied participants regarging FT3,FSH and IL-10 levels. Stress is prevalent among critical care nurses and is reflected on their psychological health with an increase in inflammatory cytokines and disturbances in endocrine functions.

Background There are few reports of mechanical circulatory support (MCS) in patients with cardiogenic shock (CS) due to end-stage heart failure (ESHF). We evaluated our institutional MCS strategy and compared the outcomes of INTERMACS 1 and 2 patients with CS due to ESHF. Methods Retrospective analysis of prospectively collected data (November 2014 to July 2019) from a single centre. ESHF was defined by a diagnosis of HF prior to presentation with CS. Other causes of CS (eg: acute myocardial infarction) were excluded. We compared the clinical course, complications and 90-day survival of patients with CS due to ESHF in INTERMACS profile 1 and 2. Results We included 60 consecutive patients with CS due to ESHF Differences in baseline characteristics were consistent with the INTERMACS profiles. The duration of MCS was similar between INTERMACS 1 and 2 patients (14 (10–33) vs 15 (7–23) days, p = 0.439). There was no significant difference in the number of patients with complications that required intervention. Compared to INTERMACS 2, INTERMACS 1 patients had more organ dysfunction on support and significant lower 90-day survival (66% vs 34%, p = 0.016). Conclusion Our temporary MCS strategy, including earlier intervention in patients with CS due to ESHF at INTERMACS 2 was associated with less organ dysfunction and better 90-day survival compared to INTERMACS 1 patients.

Objective: We assessed the clinical utility and accuracy of real-time continuous glucose monitoring (rtCGM) (Dexcom G6) in managing diabetes patients with severe COVID-19 infection following admission to the intensive care unit (ICU). Methods: We present retrospective analysis of masked rtCGM in 30 patients with severe COVID-19. rtCGM was used during the first 24 hours for comparison with arterial-line point of care (POC) values, where clinicians utilized rtCGM data to adjust insulin therapy in patients if rtCGM values were within 20% of point-of-care (POC) values during the masked period. An investigator-developed survey was administered to assess nursing staff ( n = 66) perceptions regarding the use of rtCGM in the ICU. Results: rtCGM data were used to adjust insulin therapy in 30 patients. Discordance between rtCGM and POC glucose values were observed in 11 patients but the differences were not considered clinically significant. Mean sensor glucose decreased from 235.7 ± 42.1 mg/dL (13.1 ± 2.1 mmol/L) to 202.7 ± 37.6 mg/dL (11.1 ± 2.1 mmol/L) with rtCGM management. Improvements in mean sensor glucose were observed in 77% of patients ( n = 23) with concomitant reductions in daily POC measurements in 50% of patients ( n = 15) with rtCGM management. The majority (63%) of nurses reported that rtCGM was helpful for improving care for patients with diabetes patients during the COVID-19 pandemic, and 49% indicated that rtCGM reduced their use of personal protective equipment (PPE). Conclusions: Our findings provide a strong rationale to increase clinician awareness for the adoption and implementation of rtCGM systems in the ICU. Additional studies are needed to further understand the utility of rtCGM in critically ill patients and other clinical care settings.

The COVID-19 pandemic of 2020 imposed significant strain on critical care services worldwide. The South London region experienced the largest numbers of critical care admissions in the United Kingdom with King’s College Hospital one of the busiest centres. This article outlines, using a descriptive narrative, the significant changes that occurred within King’s Critical Care as a result of the pandemic and the decisions that were taken to provide effective co-ordination and control to the expanded service, in part drawing on the military experience of two of the authors. The wider context of crisis and major incident leadership and management is also discussed contrasting different approaches used in civilian and military settings.

Background Frailty is a multi-dimensional syndrome of reduced reserve, resulting from overlapping physiological decrements across multiple systems. The contributing factors, temporality and magnitude of frailty’s effect on mortality after ICU admission are unclear. This study assessed frailty’s impact on mortality and life sustaining therapy (LST) use, following ICU admission. Methods This single-centre retrospective observational cohort study analysed data collected prospectively in Glasgow Royal Infirmary ICU. Of 684 eligible patients, 171 were frail and 513 were non-frail. Frailty was quantified using the Rockwood Clinical Frailty Scale (CFS). All patients were followed up 1-year after ICU admission. The primary outcome was all-cause mortality at 30-days post-ICU admission. Key secondary outcomes included mortality at 1-year and LST use. Results Frail patients were significantly less likely to survive 30-days post-ICU admission (61.4% vs 81.1%, p Conclusion Frailty was significantly associated with greater mortality at all time points studied, but most notably in the first 30-days post-ICU admission. This was despite greater LST use. The accrual effect of frailty increased adverse outcomes. Point-by-point use of frailty scoring could allow for more informed decision making in ICU.

Purpose Cirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-hospital mortality, hospital costs, and hospital length of stay (LOS) of IMV patients with cirrhosis. Methods We analyzed the United States National Inpatient Sample from 2005–2014. We selected discharges of IMV adult (≥18 years) patients with cirrhosis using the International Classification of Diseases, 9th Edition , Clinical Modification codes. Trends were assessed using linear regression and joinpoint regression. Results Between 2005 and 2014, there were approximately 9,441,605 hospitalizations of IMV adult patients, of which 4.7% had cirrhosis. There was an increasing trend in the total number of IMV cirrhotic patient hospitalizations (annual percent change [APC] 7.0%, 95% confidence interval [CI] 6.4%; 7.6%, Ptrend trend trend = 0.58). The total annual hospital costs of all IMV cirrhotic patients increased from approximately $1.2 billion USD in 2005 to $2.7 billion USD in 2014 ( Ptrend trend trend = 0.01 respectively). Conclusions The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time. However, past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.

Background COVID-19 has presented a unique set of psychological stressors for healthcare professionals. There is currently a dearth of literature establishing the impact amongst intensive care workers, who may be at the greatest risk. This study aimed to establish the prevalence of anxiety, depression and post-traumatic stress disorder amongst a cohort of intensive care workers within the United Kingdom. Methods A questionnaire was designed to incorporate validated screening tools for depression (Patient Health Questionnaire, PHQ-9) anxiety (Generalised Anxiety Disorder Scale, GAD-7), and post-traumatic stress disorder (Impact of Event Scale–Revised, IES-R). All intensive care workers at the Countess of Chester Hospital (UK) were eligible. Data was collected between 17th June and 8th July 2020. Results The majority of the 131 respondents were nurses (52.7% [69/131]) or doctors (32.8% [43/141]). Almost one-third (29.8% [39/131]) reported a significant or extreme impact of COVID-19 on their mental health. In total, 16%(21/131) had symptoms of moderate depression, 11.5%(15/131) moderately severe depression and 6.1%(8/131) severe depression. Females had significantly higher mean PHQ-9 scores than males (8.8 and 5.7 respectively, p = 0.009). Furthermore, 18.3% (24/131) had moderate anxiety with 14.5% (19/131) having severe anxiety. Mean GAD-7 scores were higher amongst females than males (8.7 and 6.3 respectively, p = 0.028). Additionally, 28.2% (37/131) reported symptoms consistent with a diagnosis of PTSD (IES-R ≥ 33). Despite these findings, only 3.1% (4/131) of staff accessed trust mental health support. Conclusion The impact of COVID-19 on intensive care workers is significant and warrants specific focus and attention in order to preserve this key sector of the workforce.

Introduction Cardiac disease remains the largest single cause of maternal death. Whilst uncommon, left ventricular failure during pregnancy and delivery can be devastating to both mother and child. Echocardiography can play a significant role in rapidly establishing a diagnosis, guiding initial therapy and then monitoring response. Clinical vignettes The history, presentation and management of three cases of peri-partum left ventricular failure is examined: stress cardiomyopathy in a 34 year old with twins, left ventricular dysfunction secondary to pre-eclampsia in a 22 year old with a singleton pregnancy and a true peri-partum cardiomyopathy in a 42 year old with IVF twins. The defining risk factors, presenting characteristics and echocardiographical findings for each pathology are highlighted. Conclusion Echocardiography is playing an increasingly important role in the immediate assessment and management of left ventricular failure. This is especially true in the peri-partum woman, where establishing the correct therapy is both challenging and crucial due to the significant cardiovascular changes that occur around the time of delivery. To this end we believe that echocardiography should be rapidly available to guide the management of these patients by a multidisciplinary team made up of obstetricians, cardiologists, anaesthetists and intensive care physicians.

Acute on chronic liver failure (ACLF) is a clinical syndrome characterised by acute hepatic decompensation, multi-organ failure and high mortality, in patients with cirrhosis. Organ dysfunction in ACLF is often reversible and when necessary these patients should be considered appropriate candidates for admission to an intensive care unit (ICU). The yearly increase in numbers of patients with ACLF admitted to ICU has been matched with an improvement in survival. ACLF has only been recently defined. In the absence of evidence-based guidelines we outline a systems-based approach to care which encompasses accepted ICU practice and evidence from trials in this cohort. We advocate for timely referral to specialist liver centres and consider the complexities of proceeding with liver transplantation. Equally, in a proportion of patients who continue to deteriorate, appropriate ceilings of care should be established. Future clinical trials may change treatment paradigms but care of patients with ACLF is undoubtedly becoming an integral part of an intensivist’s practice. We hope that this review is a welcome starting point when managing this complex clinical syndrome.

Background The severity of the COVID-19 health crisis has placed acute care nurses in dire work environments in which they have had to deal with uncertainty, loss, and death on a constant basis. It is necessary to gain a better understanding of nurses’ experiences to develop interventions supportive of their emotional well-being. Purpose The purpose of this study is to explore how nurses are emotionally affected working in COVID-19 acute care hospital environments. The research question is: What is the emotional experience of nurses working in COVID-19 acute care hospital environments? Methods We employed a narrative methodology that focused on participants’ stories. Twenty registered nurses, who worked in six hospitals in the Greater Toronto Area in Canada, participated in interviews. A narrative analysis was conducted with a focus on content and form of stories. Results We identified three themes about working in COVID-19 acute care hospital environments: the emotional experience, the agency of emotions, and how emotions shape nursing and practice. Conclusion In moving forth with pandemic preparations, healthcare leaders and governments need to make sure that a nurse’s sacrifice is not all-encompassing. Supporting nurses’ emotional well-being and resilience is necessary to counterbalance the loss and trauma nurses go through.

Little is known about the impact of proning on oxygenation and ventilatory efficiency on patients with severe Covid-19. In this retrospective observational study we calculated Pa/FiO2 ratio (P/F) as a marker of oxygenation and dead space fraction (Vd/Vt) to assess ventilation. 12 patients who were proned twice or more were included. There was a significant improvement in P/F ratio when prone (110.18 ± 28.11) compared to supine (88.95 ± 19.34) (p 0.05). Vd/Vt as a function of time displayed a positive linear correlation in those who did not survive (n = 9) (Rs = 0.48, p

The intensive care units in North West London are part of one of the oldest critical care networks in the UK, forming a mature and established strategic alliance to share resources, experience and knowledge for the benefit of its patients. North West London saw an early surge in COVID-19 admissions, which urgently threatened the capacity of some of its intensive care units even before the UK government announced lockdown. The pre-existing relationships and culture within the network allowed its members to unite and work rapidly to develop agile and innovative solutions, protecting any individual unit from becoming overwhelmed, and ultimately protecting its patients. Within a short 50-day period 223 patients were transferred within the network to distribute pressures. This unprecedented number of critical care transfers, combined with the creation of extra capacity and new pathways, allowed the region to continue to offer timely and unrationed access to critical care for all patients who would benefit from admission. This extraordinary response is a testament to the power and benefits of a regionally networked approach to critical care, and the lessons learned may benefit other healthcare providers, managers and policy makers, especially in regions currently facing new outbreaks of COVID-19.