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Balinskaite V, Aylin P, Bennett P, et al., 2016, Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study, Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study, Publisher: NIHR Journals Library
Background:Previous research suggests that non-obstetric surgery is carried out in 1–2% of allpregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of theevidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelinesregarding non-obstetric surgery in pregnant women.Objectives:To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgerywas or was not carried out. To further analyse common procedure groups.Data Source:Hospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.Main outcomes:Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, longinpatient stay, stillbirth and low birthweight.Methods:We utilised HES, an administrative database that includes records of all patient admissions andday cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logisticregression models to determine the adjusted relative risk and attributable risk of non-obstetric surgicalprocedures for adverse birth outcomes and the number needed to harm.Results:We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out.In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgerywas associated with a higher risk of adverse birth outcomes, although the attributable risk was generallylow. We estimated that for every 287 pregnancies in which a surgical operation was carried out there wasone additional stillbirth; for every 31 operations there was one additional preterm delivery; for every25 operations there was one additional caesarean section; for every 50 operations there was oneadditional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.Limitations:We
Taylor J, Black S, Brett S, et al., 2016, Design and implementation of the AIRWAYS-2 trial: A multi-centre cluster randomised controlled trial of the clinical and cost effectiveness of the i-gel supraglottic airway device versus tracheal intubation in the initial airway management of out of hospital cardiac arrest, Resuscitation, Vol: 109, Pages: 25-32, ISSN: 1873-1570
Health outcomes after out of hospital cardiac arrest (OHCA) are extremely poor, with only 7-9% of patients in the United Kingdom (UK) surviving to hospital discharge. Currently emergency medical services (EMS) use either tracheal intubation or newer supraglottic airway devices (SGAs) to provide advanced airway management during OHCA. Equipoise between the two techniques has led to calls for a well-designed randomised controlled trial. The primary objective of the AIRWAYS-2 trial is to assess whether the clinical effectiveness of the i-gel, a second-generation SGA, is superior to tracheal intubation in the initial airway management of OHCA patients in the UK. Paramedics recruited to the AIRWAYS-2 trial are randomised to use either tracheal intubation or i-gel as their first advanced airway intervention. Adults who have had a non-traumatic OHCA and are attended by an AIRWAYS-2 paramedic are retrospectively assessed against eligibility criteria for inclusion. The primary outcome is the modified Rankin Scale score at hospital discharge. Secondary objectives are to: (i) estimate differences between groups in outcome measures relating to airway management, hospital stay and recovery at 3 and 6 months; (ii) estimate the cost effectiveness of the i-gel compared to tracheal intubation. Because OHCA patient needs immediate treatment there are several unusual features and challenges to the design and implementation of this trial; these include level of randomisation, the automatic enrolment model, enrolment of patients that lack capacity and minimisation of bias. Patient enrolment began in June 2015. The trial will enrol 9070 patients over two years. The results are expected to influence future resuscitation guidelines. Trial Registration ISRCTN: 08256118.
Deakin CD, Yang J, Nguyen R, et al., 2016, Effects of epinephrine on cerebral oxygenation during cardiopulmonary resuscitation: A prospective cohort study, Resuscitation, Vol: 109, Pages: 138-144, ISSN: 1873-1570
BACKGROUND: Epinephrine has been presumed to improve cerebral oxygen delivery during cardiopulmonary resuscitation (CPR), but animal and registry studies suggest that epinephrine-induced capillary vasoconstriction may decrease cerebral capillary blood flow and worsen neurological outcome. The effect of epinephrine on cerebral oxygenation (rSO2) during CPR has not been documented in the clinical setting. METHODS: rSO2 was measured continuously using cerebral oximetry in patients with in-hospital cardiac arrest. During CPR, time event markers recorded the administration of 1mg epinephrine. rSO2 values were analysed for a period beginning 5min before and ending 5min after the first epinephrine administration. RESULTS: A total of 56 epinephrine doses were analysed in 36 patients during CPR. The average rSO2 value in the 5-min following epinephrine administration was 1.40% higher (95% CI=0.41-2.40%; P=0.0059) than in the 5-min period before epinephrine administration. However, there was no difference in the overall rate of change of rSO2 when comparing the 5-min period before, with the 5-min period immediately after a single bolus dose of epinephrine (0.88%/min vs 1.07%/min respectively; P=0.583), There was also no difference in the changes in rSO2 at individual 1, 2, 3, or 4-min time windows before and after a bolus dose of epinephrine (P=0.5827, 0.2371, 0.2082, and 0.6707 respectively). CONCLUSIONS: A bolus of 1mg epinephrine IV during CPR produced a small but clinically insignificant increase in rSO2 in the five minutes after administration. This is the first clinical data to demonstrate the effects of epinephrine on cerebral rSO2 during CPR.
Gordon AC, Mason AJ, Thirunavukkarasu N, et al., 2016, Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock. The VANISH Randomized Clinical Trial, The Journal of the American Medical Association, Vol: 316, Pages: 509-518, ISSN: 0002-9955
IMPORTANCE: Norepinephrine is currently recommended as the first-line vasopressor in septic shock; however, early vasopressin use has been proposed as an alternative. OBJECTIVE: To compare the effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock. DESIGN, SETTING, AND PARTICIPANTS: A factorial (2×2), double-blind, randomized clinical trial conducted in 18 general adult intensive care units in the United Kingdom between February 2013 and May 2015, enrolling adult patients who had septic shock requiring vasopressors despite fluid resuscitation within a maximum of 6 hours after the onset of shock. INTERVENTIONS: Patients were randomly allocated to vasopressin (titrated up to 0.06 U/min) and hydrocortisone (n = 101), vasopressin and placebo (n = 104), norepinephrine and hydrocortisone (n = 101), or norepinephrine and placebo (n = 103). MAIN OUTCOMES AND MEASURES: The primary outcome was kidney failure-free days during the 28-day period after randomization, measured as (1) the proportion of patients who never developed kidney failure and (2) median number of days alive and free of kidney failure for patients who did not survive, who experienced kidney failure, or both. Rates of renal replacement therapy, mortality, and serious adverse events were secondary outcomes. RESULTS: A total of 409 patients (median age, 66 years; men, 58.2%) were included in the study, with a median time to study drug administration of 3.5 hours after diagnosis of shock. The number of survivors who never developed kidney failure was 94 of 165 patients (57.0%) in the vasopressin group and 93 of 157 patients (59.2%) in the norepinephrine group (difference, -2.3% [95% CI, -13.0% to 8.5%]). The median number of kidney failure-free days for patients who did not survive, who experienced kidney failure, or both was 9 days (interquartile range [IQR], 1 to -24) in the vasopressin group and 13 days (IQR, 1
Patel PB, Brett SJ, O'Callaghan D, et al., 2016, Protocol for a randomised control trial of methylnaltrexone for the treatment of opioid-induced constipation and gastrointestinal stasis in intensive care patients (MOTION), BMJ Open, Vol: 6, ISSN: 2044-6055
Introduction: Gastro-intestinal dysmotility and constipation are common problems in intensive care patients. The majority of critical care patients are sedated with opioids to facilitate tolerance of endotracheal tubes and mechanical ventilation, which inhibit gastrointestinal motility and lead to adverse outcomes. Methylnaltrexone is a peripheral opioid antagonist that does not cross the blood-brain barrier and can reverse the peripheral side effects of opioids without affecting the desired central properties. This trial will investigate whether methylnaltrexone can reverse opioid induced constipation and gastro-intestinal dysmotility.Methods: This is a single centre, multi-site, double blind, randomised placebo controlled trial. Eighty-four patients will be recruited from four Intensive Care Units (ICU) within Imperial College Healthcare NHS Trust. Patients will receive intravenous methylnaltrexone or placebo on a daily basis if they are receiving opioid infusion to facilitate mechanical ventilation, and have not opened their bowels for 48 hours. All patients will receive standard laxatives as per the clinical ICU bowel protocol prior to randomisation. The primary outcome of the trial will be time to significant rescue-free laxation following randomisation. Secondary outcomes will include tolerance of enteral feed, gastric residual volumes, incidence of pneumonia, blood stream and Clostridium difficile infection, and any reversal of central opioid effects.Ethics and Dissemination: The trial protocol, the Patient / legal representative Information Sheets and Consent Forms have been reviewed and approved by the Harrow Research Ethics Committee (REC Reference 14/LO/2004). An independent Trial Steering Committee and Data Monitoring Committee are in place, with patient representation. Upon completion, the trial results will be published in peer-reviewed journals and presented at national and international scientific meetings.
Aylin P, Bennett P, Bottle A, et al., 2016, The risk of adverse pregnancy outcomes following non-obstetric surgery during pregnancy: An observational study, BJOG-An International Journal of Obstetrics and Gynaecology, Vol: 123, Pages: 84-84, ISSN: 1471-0528
Brett SJ, 2016, Late mortality after sepsis, British Medical Journal, Vol: 353, ISSN: 1756-1833
Arulkumaran N, Reay H, Brett SJ, et al., 2016, Research priorities by professional background - A detailed analysis of the James Lind Alliance Priority Setting Partnership, Journal of the Intensive Care Society, Vol: 17, Pages: 111-116, ISSN: 1751-1437
The Intensive Care Foundation, in partnership with the James Lind Alliance, has supported a national project to identify and prioritise unanswered questions about adult intensive care that are important to people who have been critically ill, their families, and the health professionals who care for them. We conducted a secondary analysis to explore differences in priorities determined by different respondent groups in order to identify different groups' perceptions of gaps in knowledge. There were two surveys conducted as part of the original project. Survey 1 comprised a single open question to identify important research topics; survey 2 aimed to prioritise these topics using a 10-point Likert scale. In survey 1, despite clear differences in suggestions amongst the respondent groups, themes of comfort/communication and post-ICU rehabilitation were the within the top 2 suggestions across all groups. Patients and relatives suggested research topics to which they could easily relate, whereas there was a greater breadth of suggestions from clinicians. In survey 2, the number of research priorities that received a mode score of 10 varied from 1 to 36. Patients scored 36 out of the 37 topics with a mode score of 10. All other groups scored topics with more discrimination, with the number of topics with a mode score of 10 ranging from 1 to 20. Differences in the proportions of the representative groups are therefore unlikely to have translated to an impartial conclusion. Clinicians, patients, and family members have jointly identified the research priorities for UK ICM practice.
Parnia S, Yang J, Nguyen R, et al., 2016, Cerebral oximetry during cardiac arrest: a multicenter study of neurologic outcomes and survival, Critical Care Medicine, Vol: 44, Pages: 1663-1674, ISSN: 0090-3493
OBJECTIVES: Cardiac arrest is associated with morbidity and mortality because of cerebral ischemia. Therefore, we tested the hypothesis that higher regional cerebral oxygenation during resuscitation is associated with improved return of spontaneous circulation, survival, and neurologic outcomes at hospital discharge. We further examined the validity of regional cerebral oxygenation as a test to predict these outcomes. DESIGN: Multicenter prospective study of in-hospital cardiac arrest. SETTING: Five medical centers in the United States and the United Kingdom. PATIENTS: Inclusion criteria are as follows: in-hospital cardiac arrest, age 18 years old or older, and prolonged cardiopulmonary resuscitation greater than or equal to 5 minutes. Patients were recruited consecutively during working hours between August 2011 and September 2014. Survival with a favorable neurologic outcome was defined as a cerebral performance category 1-2. INTERVENTIONS: Cerebral oximetry monitoring. MEASUREMENTS AND MAIN RESULTS: Among 504 in-hospital cardiac arrest events, 183 (36%) met inclusion criteria. Overall, 62 of 183 (33.9%) achieved return of spontaneous circulation, whereas 13 of 183 (7.1%) achieved cerebral performance category 1-2 at discharge. Higher mean ± SD regional cerebral oxygenation was associated with return of spontaneous circulation versus no return of spontaneous circulation (51.8% ± 11.2% vs 40.9% ± 12.3%) and cerebral performance category 1-2 versus cerebral performance category 3-5 (56.1% ± 10.0% vs 43.8% ± 12.8%) (both p < 0.001). Mean regional cerebral oxygenation during the last 5 minutes of cardiopulmonary resuscitation best predicted the return of spontaneous circulation (area under the curve, 0.76; 95% CI, 0.69-0.83); regional cerebral oxygenation greater than or equal to 25% provided 100% sensitivity (95% CI, 94-100) and 100% negative predictive value (95% CI, 79-100); regional cerebral oxygenation greater than or equal t
Fotopoulou C, Jones BP, Savvatis K, et al., 2016, Maximal effort cytoreductive surgery for disseminated ovarian cancer in a UK setting: challenges and possibilities, Gynecologic Oncology, ISSN: 1095-6859
OBJECTIVE: To assess surgical morbidity and mortality of maximal effort cytoreductive surgery for disseminated epithelial ovarian cancer (EOC) in a UK tertiary center. METHODS/MATERIALS: A monocentric prospective analysis of surgical morbidity and mortality was performed for all consecutive EOC patients who underwent extensive cytoreductive surgery between 01/2013 and 12/2014. Surgical complexity was assessed by the Mayo clinic surgical complexity score (SCS). Only patients with high SCS ≥5 were included in the analysis. RESULTS: We evaluated 118 stage IIIC/IV patients, with a median age of 63 years (range 19-91); 47.5 % had ascites and 29 % a pleural effusion. Median duration of surgery was 247 min (range 100-540 min). Median surgical complexity score was 10 (range 5-15) consisting of bowel resection (71 %), stoma formation (13.6 %), diaphragmatic stripping/resection (67 %), liver/liver capsule resection (39 %), splenectomy (20 %), resection stomach/lesser sac (26.3 %), pleurectomy (17 %), coeliac trunk/subdiaphragmatic lymphadenectomy (8 %). Total macroscopic tumor clearance rate was 89 %. Major surgical complication rate was 18.6 % (n = 22), with a 28-day and 3-month mortality of 1.7 and 3.4 %, respectively. The anastomotic leak rate was 0.8 %; fistula/bowel perforation 3.4 %; thromboembolism 3.4 % and reoperation 4.2 %. Median intensive care unit and hospital stay were 1.7 (range 0-104) and 8 days (range 4-118), respectively. Four patients (3.3 %) failed to receive chemotherapy within the first 8 postoperative weeks. CONCLUSIONS: Maximal effort cytoreductive surgery for EOC is feasible within a UK setting with acceptable morbidity, low intestinal stoma rates and without clinically relevant delays to postoperative chemotherapy. Careful patient selection, and coordinated multidisciplinary effort appear to be the key for good outcome. Future ev
Patel A, Jhanji S, Pavlu J, et al., 2016, Mesenchymal stromal stem cell (MSC) immunotherapy for experimental septic shock: systematic review and meta-analysis with trial sequential analysis of mortality, 42nd Annual Meeting of the European Society for Blood and Marrow Transplantation, Publisher: Nature Publishing Group, Pages: S129-S129, ISSN: 1476-5365
Shepherd SJ, Newman R, Brett SJ, et al., 2016, Pharmacological Therapy for the Prevention and Treatment of Weakness After Critical Illness: A Systematic Review., Critical Care Medicine, Vol: 44, Pages: 1198-1205, ISSN: 1530-0293
OBJECTIVES: ICU-acquired weakness is a common complication of critical illness and can have significant effects upon functional status and quality of life. As part of preliminary work to inform the design of a randomized trial of a complex intervention to improve recovery from critical illness, we sought to identify pharmacological interventions that may play a role in this area. DATA SOURCES: We systematically reviewed the published literature relating to pharmacological intervention for the treatment and prevention of ICU-acquired weakness. STUDY SELECTION: We searched MEDLINE, EMBASE, CINAHL+, Web of Science, and both U.S. and European trial registries up to July 2014 alongside reviews and reference lists from populations with no age or language restrictions. We included studies that reported a measure of muscle structure or physical function as an outcome measure. DATA EXTRACTION: We estimated pooled odds ratios and 95% CI using data extracted from published articles or where available, original data provided by the authors. Assessment of bias was performed using the Cochrane Collaboration's risk of bias tool. DATA SYNTHESIS: Ten studies met the inclusion criteria. The current body of evidence does not support the use of any pharmacological agent in this setting, although maintaining euglycemia may reduce the prevalence of critical illness polyneuropathy. CONCLUSIONS: At present, no pharmacological intervention can be recommended to prevent or treat ICU-acquired weakness. Further research is required into this field to include more novel agents such as myostatin inhibitors. Challenges in the conduct of research in this area are highlighted.
Corner E, Handy JM, Brett SJ, 2016, eLearning to facilitate the education and implementation of The Chelsea Critical Care Physical Assessment: a novel measure of function in critical illness., BMJ Open, Vol: 6, ISSN: 2044-6055
Objective: To evaluate the efficacy of eLearning in the widespread standardized teaching,distribution and implementation of The Chelsea Critical Care Physical Assessment tool (CPAx): avalidated tool to assess physical function in critically ill patients.Design: Prospective educational study. An eLearning module was developed through aconceptual framework, using the four-stage technique for skills teaching to teach clinicians howto use the CPAx. Example and test video case studies of CPAx assessments were embeddedwithin the module. The CPAx scores for the test case studies and demographic data wererecorded in a secure area of the website. Data were analyzed for inter-rater reliability usingintraclass correlation coefficients (ICC) to see if an eLearning educational package facilitatedconsistent use of the tool. A utility and content validity questionnaire was distributed after oneyear to eLearning module registrants (n= 971). This was to evaluate uptake of the CPAx inclinical practice and content validity of the CPAx from the perspective of clinical users.Setting: The module was distributed for use via professional forums (n=2) and direct contacts(n=95)Participants: Critical care cliniciansPrimary outcome measure: Intraclass correlation co-efficient of the test case studies.Results: Between July and October 2014, 421 candidates from fifteen countries registered forthe eLearning module. The ICC for case one was 0.996 (95% CI 0.990-0.999; n=207). The ICC for case two was .988 (0.996-1.000; n=184). The CPAx has a strong total scale content validityindex (s-CVI) of 0.94 and is well utilized.Conclusions: eLearning is a useful and reliable way of teaching psychomotor skills, such as theCPAx. The CPAx is a well-utilized measure with high content validity rated by clinicians.
Walsh T, Brett SJ, 2015, What are the priorities for future success in critical care research in the UK? Report from a national stakeholder meeting., J Intensive Care Soc, Vol: 16, Pages: 287-293, ISSN: 1751-1437
Critical care in the United Kingdom is now well-established in terms of professional status, standards of clinical practice and training, and national audit through professional bodies and government representation. Research is fundamental to the further development and maturation of the specialty, to develop new therapies and technologies, more efficient and effective service organisation, and to improve patient and family experience and outcomes. Critical care research has expanded rapidly in the UK, and now has established organisations and infrastructure to share and develop ideas, through the UK Critical Care Research Forum and similar meetings. In September 2014, the Intensive Care Foundation and Critical Care Leadership Forum hosted a research colloquium to reflect, in part, on achievements, but more importantly plan for the future. With an invited list of participants the meeting explored firstly - the practical delivery of clinical research and secondly - the future financing landscape, from both academic funders' and commercial developers' perspectives. The following article summarises the important 'take home' messages from this meeting and suggests key issues for future strategy.
Perkins GD, Jacobs IG, Nadkarni VM, et al., 2015, Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest: A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation., Resuscitation, Vol: 96, Pages: 328-340
Utstein-style guidelines contribute to improved public health internationally by providing a structured framework with which to compare emergency medical services systems. Advances in resuscitation science, new insights into important predictors of outcome from out-of-hospital cardiac arrest, and lessons learned from methodological research prompted this review and update of the 2004 Utstein guidelines. Representatives of the International Liaison Committee on Resuscitation developed an updated Utstein reporting framework iteratively by meeting face to face, by teleconference, and by Web survey during 2012 through 2014. Herein are recommendations for reporting out-of-hospital cardiac arrest. Data elements were grouped by system factors, dispatch/recognition, patient variables, resuscitation/postresuscitation processes, and outcomes. Elements were classified as core or supplemental using a modified Delphi process primarily based on respondents' assessment of the evidence-based importance of capturing those elements, tempered by the challenges to collect them. New or modified elements reflected consensus on the need to account for emergency medical services system factors, increasing availability of automated external defibrillators, data collection processes, epidemiology trends, increasing use of dispatcher-assisted cardiopulmonary resuscitation, emerging field treatments, postresuscitation care, prognostication tools, and trends in organ recovery. A standard reporting template is recommended to promote standardized reporting. This template facilitates reporting of the bystander-witnessed, shockable rhythm as a measure of emergency medical services system efficacy and all emergency medical services system-treated arrests as a measure of system effectiveness. Several additional important subgroups are identified that enable an estimate of the specific contribution of rhythm and bystander actions that are key determinants of outcome.
Stacey MJ, Parsons I, Woods DR, et al., 2015, Susceptibility to exertional heat illness and hospitalisation risk in United Kingdom military personnel, BMJ Open Sports and Exercise Medicine, Vol: 1, ISSN: 2055-7647
Background: Susceptibility to exertional heat illness(EHI) is considered multifactorial in nature. The aims ofthis study were to (1) review traditional susceptibilityfactors identified in cases of EHI and (2) determinehow they are related to risk of hospitalisation.Methods: Review of an electronic database of EHIreported in the British Army between 1 September2007 and 31 December 2014. Cases were categorisedby demographic, situational and susceptibilityvariables. Univariate and multivariate logistic regressionwas performed for the OR for hospitalisation by riskfactor.Results: 361 reports were included in the analysis.33.5% of cases occurred in hot climates, 34.6% intemperate climates during summer months and 31.9%in temperate climates outside of summer months.Traditional susceptibility factors were reported in 193but entirely absent from 168 cases. 137 cases (38.0%)were admitted to hospital. Adjusted OR forhospitalisation was lower for recruits (OR 0.42, 95% CI0.18 to 0.99, p<0.05) and for personnel wearingocclusive dress (OR 0.56, 95% CI 0.34 to 0.93,p<0.05) or unacclimatised to heat (OR 0.31, 95% CI0.15 to 0.66, p<0.01).Conclusions: The global, year-round threat of EHI ishighlighted. Absence of susceptibility factors in nearlyhalf of reports highlights the challenge of identifyingEHI-prone individuals. Paradoxical association oftraditional susceptibility factors with reducedhospitalisation risk may reflect the contemporarycontexts in which severe EHI occurs. These findingsalso suggest a need for better evidence to informguidelines that aim to prevent severe EHI concurrent toreducing overall morbidity.
Abdul-Aziz MH, Lipman J, Akova M, et al., 2015, Is prolonged infusion of piperacillin/tazobactam and meropenem in critically ill patients associated with improved pharmacokinetic/pharmacodynamic and patient outcomes? An observation from the Defining Antibiotic Levels in Intensive care unit patients (DALI) cohort., Journal of Antimicrobial Chemotherapy, Vol: 71, Pages: 196-207, ISSN: 0305-7453
OBJECTIVES: We utilized the database of the Defining Antibiotic Levels in Intensive care unit patients (DALI) study to statistically compare the pharmacokinetic/pharmacodynamic and clinical outcomes between prolonged-infusion and intermittent-bolus dosing of piperacillin/tazobactam and meropenem in critically ill patients using inclusion criteria similar to those used in previous prospective studies. METHODS: This was a post hoc analysis of a prospective, multicentre pharmacokinetic point-prevalence study (DALI), which recruited a large cohort of critically ill patients from 68 ICUs across 10 countries. RESULTS: Of the 211 patients receiving piperacillin/tazobactam and meropenem in the DALI study, 182 met inclusion criteria. Overall, 89.0% (162/182) of patients achieved the most conservative target of 50% fT>MIC (time over which unbound or free drug concentration remains above the MIC). Decreasing creatinine clearance and the use of prolonged infusion significantly increased the PTA for most pharmacokinetic/pharmacodynamic targets. In the subgroup of patients who had respiratory infection, patients receiving β-lactams via prolonged infusion demonstrated significantly better 30 day survival when compared with intermittent-bolus patients [86.2% (25/29) versus 56.7% (17/30); P = 0.012]. Additionally, in patients with a SOFA score of ≥9, administration by prolonged infusion compared with intermittent-bolus dosing demonstrated significantly better clinical cure [73.3% (11/15) versus 35.0% (7/20); P = 0.035] and survival rates [73.3% (11/15) versus 25.0% (5/20); P = 0.025]. CONCLUSIONS: Analysis of this large dataset has provided additional data on the niche benefits of administration of piperacillin/tazobactam and meropenem by prolonged infusion in critically ill patients, particularly for patients with respiratory infections.
Connolly B, O'Neill B, Salisbury L, et al., 2015, Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery: an overview of systematic reviews protocol., Syst Rev, Vol: 4
BACKGROUND: Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery. METHODS/DESIGN: This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool. DISCUSSION: We anticipate the findings from this novel overview of systematic
Perkins GD, Jacobs IG, Nadkarni VM, et al., 2015, Cardiac Arrest and Cardiopulmonary Resuscitation Outcome Reports: Update of the Utstein Resuscitation Registry Templates for Out-of-Hospital Cardiac Arrest A Statement for Healthcare Professionals From a Task Force of the International Liaison Committee on Resuscitation (American Heart Association, European Resuscitation Council, Australian and New Zealand Council on Resuscitation, Heart and Stroke Foundation of Canada, InterAmerican Heart Foundation, Resuscitation Council of Southern Africa, Resuscitation Council of Asia); and the American Heart Association Emergency Cardiovascular Care Committee and the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, CIRCULATION, Vol: 132, Pages: 1286-1300, ISSN: 0009-7322
Wandrag L, Brett SJ, Frost G, et al., 2015, Impact of supplementation with amino acids or their metabolites on muscle wasting in patients with critical illness or other muscle wasting illness: a systematic review, JOURNAL OF HUMAN NUTRITION AND DIETETICS, Vol: 28, Pages: 313-330, ISSN: 0952-3871
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Connolly B, Salisbury L, O'Neill B, et al., 2015, Exercise rehabilitation following intensive care unit discharge for recovery from critical illness., Cochrane Database Syst Rev, Vol: 2015
BACKGROUND: Skeletal muscle wasting and weakness are significant complications of critical illness, associated with degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and can markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients after critical illness. Exercise-based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However, its effectiveness when initiated after ICU discharge has yet to be established. OBJECTIVES: To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, for functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated longer than 24 hours. SEARCH METHODS: We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid SP MEDLINE, Ovid SP EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host to 15 May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015 and will deal with the three studies of interest when we update the review. SELECTION CRITERIA: We included randomized contr
Moore AC, Stacey MJ, Bailey KG, et al., 2015, Risk factors for heat illness among British soldiers in the hot Collective Training Environment., Journal of the Royal Army Medical Corps, Vol: 162, Pages: 434-439, ISSN: 0035-8665
BACKGROUND: Heat illness is a preventable disorder in military populations. Measures that protect vulnerable individuals and contribute to effective Immediate Treatment may reduce the impact of heat illness, but depend upon adequate understanding and awareness among Commanders and their troops. OBJECTIVE: To assess risk factors for heat illness in British soldiers deployed to the hot Collective Training Environment (CTE) and to explore awareness of Immediate Treatment responses. METHODS: An anonymous questionnaire was distributed to British soldiers deployed in the hot CTEs of Kenya and Canada. Responses were analysed to determine the prevalence of individual (Intrinsic) and Command-practice (Extrinsic) risk factors for heat illness and the self-reported awareness of key Immediate Treatment priorities (recognition, first aid and casualty evacuation). RESULTS: The prevalence of Intrinsic risk factors was relatively low in comparison with Extrinsic risk factors. The majority of respondents were aware of key Immediate Treatment responses. The most frequently reported factors in each domain were increased risk by body composition scoring, inadequate time for heat acclimatisation and insufficient briefing about casualty evacuation. CONCLUSIONS: Novel data on the distribution and scale of risk factors for heat illness are presented. A collective approach to risk reduction by the accumulation of 'marginal gains' is proposed for the UK military. This should focus on limiting Intrinsic risk factors before deployment, reducing Extrinsic factors during training and promoting timely Immediate Treatment responses within the hot CTE.
Hernandez-Silveira M, Ahmed K, Ang SS, et al., 2015, Assessment of the feasibility of an ultra-low power, wireless digital patch for the continuous ambulatory monitoring of vital signs., BMJ Open, Vol: 5, Pages: e006606-e006606, ISSN: 2044-6055
BACKGROUND AND OBJECTIVES: Vital signs are usually recorded at 4-8 h intervals in hospital patients, and deterioration between measurements can have serious consequences. The primary study objective was to assess agreement between a new ultra-low power, wireless and wearable surveillance system for continuous ambulatory monitoring of vital signs and a widely used clinical vital signs monitor. The secondary objective was to examine the system's ability to automatically identify and reject invalid physiological data. SETTING: Single hospital centre. PARTICIPANTS: Heart and respiratory rate were recorded over 2 h in 20 patients undergoing elective surgery and a second group of 41 patients with comorbid conditions, in the general ward. OUTCOME MEASURES: Primary outcome measures were limits of agreement and bias. The secondary outcome measure was proportion of data rejected. RESULTS: The digital patch provided reliable heart rate values in the majority of patients (about 80%) with normal sinus rhythm, and in the presence of abnormal ECG recordings (excluding aperiodic arrhythmias such as atrial fibrillation). The mean difference between systems was less than ±1 bpm in all patient groups studied. Although respiratory data were more frequently rejected as invalid because of the high sensitivity of impedance pneumography to motion artefacts, valid rates were reported for 50% of recordings with a mean difference of less than ±1 brpm compared with the bedside monitor. Correlation between systems was statistically significant (p<0.0001) for heart and respiratory rate, apart from respiratory rate in patients with atrial fibrillation (p=0.02). CONCLUSIONS: Overall agreement between digital patch and clinical monitor was satisfactory, as was the efficacy of the system for automatic rejection of invalid data. Wireless monitoring technologies, such as the one tested, may offer clinical value when implemented as part of wider hospital systems that integrate and supp
Nyland GA, Mckenzie BC, Myles PR, et al., 2015, Effect of ethnicity on care pathway and outcomes in patients hospitalized with influenza A(H1N1)pdm09 in the UK, EPIDEMIOLOGY AND INFECTION, Vol: 143, Pages: 1129-1138, ISSN: 0950-2688
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- Citations: 9
Hill NE, Saeed S, Phadke R, et al., 2015, Detailed characterization of a long-term rodent model of critical illness and recovery, Critical Care Medicine, Vol: 43, Pages: E84-E96, ISSN: 0090-3493
Objective: To characterize a long-term model of recovery from critical illness, with particular emphasis on cardiorespiratory, metabolic, and muscle function.Design: Randomized controlled animal study.Setting: University research laboratory.Subjects: Male Wistar rats.Interventions: Intraperitoneal injection of the fungal cell wall constituent, zymosan or n-saline.Measurements and Main Results: Following intervention, rats were followed for up to 2 weeks. Animals with zymosan peritonitis reached a clinical and biochemical nadir on day 2. Initial reductions were seen in body weight, total body protein and fat, and muscle mass. Leg muscle fiber diameter remained subnormal at 14 days with evidence of persisting myonecrosis, even though gene expression of regulators of muscle mass (e.g., MAFbx, MURF1, and myostatin) had peaked on days 2–4 but normalized by day 7. Treadmill exercise capacity, forelimb grip strength, and in vivo maximum tetanic force were also reduced. Food intake was minimal until day 4 but increased thereafter. This did not relate to appetite hormone levels with early (6 hr) rises in plasma insulin and leptin followed by persisting subnormal levels; ghrelin levels did not change. Serum interleukin-6 level peaked at 6 hours but had normalized by day 2, whereas interleukin-10 remained persistently elevated and high-density lipoprotein cholesterol persistently depressed. There was an early myocardial depression and rise in core temperature, yet reduced oxygen consumption and respiratory exchange ratio with a loss of diurnal rhythmicity that showed a gradual but incomplete recovery by day 7.Conclusions: This detailed physiological, metabolic, hormonal, functional, and histological muscle characterization of a model of critical illness and recovery reproduces many of the findings reported in human critical illness. It can be used to assess putative therapies that may attenuate loss, or enhance recovery, of muscle mass and function.
Hill NE, Fallowfield JL, Delves SK, et al., 2015, Changes in Gut Hormones and Leptin in Military Personnel During Operational Deployment in Afghanistan, OBESITY, Vol: 23, Pages: 608-614, ISSN: 1930-7381
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- Citations: 8
Corner EJ, Hichens LV, Attrill KM, et al., 2015, The responsiveness of the Chelsea Critical Care Physical Assessment tool in measuring functional recovery in the burns critical care population: An observational study, BURNS, Vol: 41, Pages: 241-247, ISSN: 0305-4179
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- Citations: 25
Hill NE, Woods DR, Delves SK, et al., 2015, The gonadotrophic response of Royal Marines during an operational deployment in Afghanistan, ANDROLOGY, Vol: 3, Pages: 293-297, ISSN: 2047-2919
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- Citations: 7
Petrie J, Easton S, Naik V, et al., 2015, Hospital costs of out-of-hospital cardiac arrest patients treated in intensive care; a single centre evaluation using the national tariff-based system, BMJ Open, Vol: 5, ISSN: 2044-6055
D'Lima DM, Moore J, Bottle A, et al., 2015, Developing effective feedback on quality of anaesthetic care: what are its most valuable characteristics from a clinical perspective?, JOURNAL OF HEALTH SERVICES RESEARCH & POLICY, Vol: 20, Pages: 26-34, ISSN: 1355-8196
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- Citations: 10
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