Alex Puxty

Defining the characteristics and expectations of fluid bolus therapy: A worldwide perspective

PURPOSE The purpose of the study is to understand what clinicians believe defines fluid bolus therapy (FBT) and the expected response to such intervention. METHODS We asked intensive care specialists in 30 countries to participate in an electronic questionnaire of their practice, definition, and expectations of FBT. RESULTS We obtained 3138 responses. Despite much variation, more than 80% of respondents felt that more than 250 mL of either colloid or crystalloid fluid given over less than 30 minutes defined FBT, with crystalloids most acceptable. The most acceptable crystalloid and colloid for use as FBT were 0.9% saline and 4% albumin solution, respectively. Most respondents believed that one or more of the following physiological changes indicates a response to FBT: a mean arterial pressure increase greater than 10 mm Hg, a heart rate decrease greater than 10 beats per minute, an increase in urinary output by more than 10 mL/h, an increase in central venous oxygen saturation greater than 4%, or a lactate decrease greater than 1 mmol/L. CONCLUSIONS Despite wide variability between individuals and countries, clear majority views emerged to describe practice, define FBT, and identify a response to it. Further investigation is now required to describe actual FBT practice and to identify the magnitude and duration of the physiological response to FBT and its relationship to patient-centered outcomes.

Validation and analysis of prognostic scoring systems for critically ill patients with cirrhosis admitted to ICU

IntroductionThe number of patients admitted to ICU who have liver cirrhosis is rising. Current prognostic scoring tools to predict ICU mortality have performed poorly in this group. In previous research from a single centre, a novel scoring tool which modifies the Child-Turcotte Pugh score by adding Lactate concentration, the CTP + L score, is strongly associated with mortality. This study aims to validate the use of the CTP + L scoring tool for predicting ICU mortality in patients admitted to a general ICU with cirrhosis, and to determine significant predictive factors for mortality with this group of patients. This study will also explore the use of the Royal Free Hospital (RFH) score in this cohort.MethodsA total of 84 patients admitted to the Glasgow Royal Infirmary ICU between June 2012 and Dec 2013 with cirrhosis were included. An additional cohort of 115 patients was obtained from two ICUs in London (St George’s and St Thomas’) collected between October 2007 and July 2009. Liver specific and general ICU scoring tools were calculated for both cohorts, and compared using area under the receiver operating characteristic (ROC) curves. Independent predictors of ICU mortality were identified by univariate analysis. Multivariate analysis was utilised to determine the most predictive factors affecting mortality within these patient groups.ResultsWithin the Glasgow cohort, independent predictors of ICU mortality were identified as Lactate (p < 0.001), Bilirubin (p = 0.0048), PaO2/FiO2 Ratio (p = 0.032) and PT ratio (p = 0.012). Within the London cohort, independent predictors of ICU mortality were Lactate (p < 0.001), PT ratio (p < 0.001), Bilirubin (p = 0.027), PaO2/FiO2 Ratio (p = 0.0011) and Ascites (p = 0.023). The CTP + L and RFH scoring tools had the highest ROC value in both cohorts examined.ConclusionThe CTP + L and RFH scoring tool are validated prognostic scoring tools for predicting ICU mortality in patients admitted to a general ICU with cirrhosis.

Do alcohol use disorders impact on long term outcomes from intensive care

IntroductionThere is limited evidence regarding the impact of alcohol use disorders on long term outcomes from intensive care. The aims of this study were to analyse the nature and complications of alcohol related admissions to intensive care and determine whether alcohol use disorders impact on survival at six months post ICU discharge.MethodThis was an 18 month prospective observational cohort study in a 20 bedded mixed ICU, in a large teaching hospital in Scotland. On admission patients were allocated to one of three alcohol groups: low risk, harmful/hazardous, or alcohol dependency.Results34.4% of patients were admitted with an alcohol use disorder. Those with an alcohol related admission (either harmful/hazardous or alcohol dependent) had an increased odds of developing septic shock during their admission, compared with the low risk group (OR 1.67; 95% CI 1.13-2.47, p = 0.01). After adjustment for all lifestyle factors which were significantly different between the groups, alcohol dependence was associated with more than a twofold increased odds of ICU mortality (OR 2.28; 95% CI 1.2-4.69, p = 0.01) and hospital mortality (OR 2.43; 95% CI 1.28-4.621, p = 0.004). After adjustment for deprivation category and age, alcohol dependence was associated with an almost two fold increased odds of mortality at six months post ICU discharge (HR 1.86; CI 1.30-2.70, p = 0.001).ConclusionAlcohol use disorders are a significant risk factor for the development of septic shock in intensive care. Further, alcohol dependency is independently associated with poorer long term outcomes from intensive care.

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

PURPOSE This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting. METHODS This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed. RESULTS Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86). CONCLUSIONS This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.

Provision of trauma teams in Scotland: a national survey

Background and aims Trauma is still the leading cause of mortality in the first four decades of life. Despite numerous reports on how trauma care could be improved in the UK, treatment has been shown to be inconsistent and of poor quality. Trauma teams have been shown to have a positive effect on outcome. A study was undertaken to determine the prevalence of trauma teams in Scotland. Methods A telephone survey was performed of 24 hospitals with emergency departments in which the senior clinician was interviewed regarding the provision of trauma teams. Results Five (21%) of the hospitals questioned had trauma teams. The most common reasons for not having one were no problem with the current system in eight cases (44%) and an inability to include sufficiently senior staff on the team in six cases (24%). Conclusions There are few trauma teams in Scottish acute hospitals. There was little enthusiasm for introducing them for a variety of reasons. Local evidence of benefit is probably needed before their adoption becomes widespread.

Recombinant activated protein C usage in Scotland: a comparison with published guidelines and a survey of attitudes*

Severe sepsis is a common cause of admission to the intensive care unit and is associated with a high hospital mortality. This audit explored the current use of, and attitudes towards, recombinant activated protein C therapy across Scotland, and compared these with current guidance. Patients with severe sepsis were followed for three days. Consideration and/or usage of recombinant activated protein C were compared with two different guidelines. Ninety‐seven patients were admitted to the intensive care unit over the audit period. Recombinant activated protein C was used in nine of these patients. Depending on the criteria used, between 50% and 81% of the patients who qualified for recombinant activated protein C therapy did not receive it. Subsequent to the audit, a survey was performed to study intensive care unit consultants’ attitudes to recombinant activated protein C therapy. A total of 125 consultants responded to the survey (77%). Of these, 104 (83%) stated that they used recombinant activated protein C in their clinical practice, 56 (52%) of whom prescribed it to patients with two‐organ failures and an Acute Physiology and Chronic Health Evaluation II score of ≥ 25. Thirty‐nine respondents (38%) stated that two‐organ failures alone would be an adequate trigger for therapy. We conclude that recombinant activated protein C is potentially under‐used to treat severe sepsis. Many consultants seem to reserve the drug for the most severely ill sub group of patients.

Factors influencing intensive care admission: a mixed methods study of EM and ICU.

Objectives Twenty-six percent of ICU patients in the UK are referred directly from the Emergency Department (ED). There is limited literature examining the attitudes or practice of ED/ICU physicians towards referrals from the ED to the ICU. We examined these attitudes through a mixed methods study, designing a model incorporating these attitudes to promote a shared mental model between ED and ICU specialities. Methods Individual semistructured interviews were conducted with 11 ED consultants and 11 ICU consultants at two hospitals in the west of Scotland. Interviews were based on 10 ‘case-based vignettes’ representing patients for whom referral from the ED to the ICU is borderline or challenging. Participants were asked to note whether they would refer/accept the patient from the ED to the ICU. The proportions of participants from each speciality choosing to refer or accept patients were compared using a t-test comparing proportions. The reasons behind these decisions were explored during the semistructured interviews. Results Twelve factors emerged as influencing the decisions made by the participants. These belonged three core themes: patient factors, clinician factors and resource factors, which were incorporated into a shared mental model. Two cases demonstrated statistically significant differences in referral rates between specialities. There were also clinically significant differences among other cases. Conclusion We have described the attitudes of physicians towards ED to ICU referrals in two west of Scotland hospitals, and we have demonstrated that there is a difference in the aspects of the decision-making process. We have developed a model encompassing all factors considered by participants when assessing these difficult referrals. It is hoped that this model will promote shared and more efficient decision-making in the future.

Making Quality Improvement Happen in the Real World: Building Capability and Improving Multiple Projects at the Same Time

Improving work as part of clinical practice is challenging. Plans for improvement are often made, but not followed through. A recent experience of failure in an ICU led to a change in approach. Members of the multi-professional team committed to meet weekly to learn about quality improvement by working on improvement projects. The group selected four topics they wanted to work on. These were: a bundle for patients admitted with septic shock; early (≤4 hours) sedation vacation after admission to ICU to allow titration of sedation to effect; achieving ≥ 20 minutes of mobilisation per day in ventilated patients; and medicines reconciliation. This quality improvement meeting was built into another regular weekly meeting. Initially the meeting ran for 30 minutes; each week some focused quality improvement teaching was provided in addition to talking about each individual project. The team found the meeting useful, they saw the progress they were making but felt the allotted time was too short. After 6 weeks, the initial early results persuaded the team to increase the duration of this meeting to 45 minutes. At the start reliability of each process was low (between 10% and 38%). All four projects achieved their stated process reliability aim. This took between 165 and 334 days for each project. Many tests of change ideas were required to achieve this. We have been able to improve multiple topics in a short period and produce sustainable change. The weekly meeting provided the focus to this improvement work. The teaching and coaching on quality improvement methodology that occurred as part of this meeting helped accelerate our rate of progress. We believe this experience and the learning we have gained will help provide ideas for others who also want to improve healthcare delivery in different settings.

Propofol is not safe for sedation for hip relocation

We read with interest the clinically based study of Mathieu et al on the use of propofol to sedate patients for relocation of hip prostheses in the emergency department.1 The authors rightly point out that there are problems with the safety and efficacy of using midazolam, and conclude that the described technique is effective and safe. In another paper by the same authors, they demonstrate that this technique of ‘sedation’ has a better success than midazolam and reduces the delay in these patients going to theatre and therefore the discomfort the patients may experience (although there is no mention of pain scores of these patients).2 However, we disagree strongly with the conclusions that the adverse effects were acceptably uncommon and argue that the authors have not demonstrated the safety of this technique. First, we would like to comment on the sedation protocol. Disappointingly there is no attempt to describe the depth of sedation provided. The report of the Academy of Royal Colleges …

The influence of alcohol abuse on agitation, delirium and sedative requirements of patients admitted to a general intensive care unit

Purpose Patients with alcohol-related disease constitute an increasing proportion of those admitted to intensive care unit. There is currently limited evidence regarding the impact of alcohol use on levels of agitation, delirium and sedative requirements in intensive care unit. This study aimed to determine whether intensive care unit-admitted alcohol-abuse patients have different sedative requirements, agitation and delirium levels compared to patients with no alcohol issues. Methods This retrospective analysis of a prospectively acquired database (June 2012–May 2013) included 257 patients. Subjects were stratified into three risk categories: alcohol dependency (n = 69), at risk (n = 60) and low risk (n = 128) according to Fast Alcohol Screening Test scores and World Health Organisation criteria for alcohol-related disease. Data on agitation and delirium were collected using validated retrospective chart-screening methods and sedation data were extracted and then log-transformed to fit the regression model. Results Incidence of agitation (p = 0.034) and delirium (p = 0.041) was significantly higher amongst alcohol-dependent patients compared to low-risk patients as was likelihood of adverse events (p = 0.007). In contrast, at-risk patients were at no higher risk of these outcomes compared to the low-risk group. Alcohol-dependent patients experienced suboptimal sedation levels more frequently and received a wider range of sedatives (p = 0.019) but did not receive higher daily doses of any sedatives. Conclusions Our analysis demonstrates that when admitted to intensive care unit, it is those who abuse alcohol most severely, alcohol-dependent patients, rather than at-risk drinkers who have a significantly increased risk of agitation, delirium and suboptimal sedation. These patients may require closer assessment and monitoring for these outcomes whilst admitted.