Carl Waldmann

Rehabilitation after critical illness: A randomized, controlled trial

ObjectiveTo evaluate the effectiveness of a rehabilitation program following critical illness to aid physical and psychological recovery. DesignRandomized controlled trial, blind at follow-up with final assessment at 6 months. SettingTwo district general hospitals and one teaching hospital. PatientsPatients were 126 consecutively admitted intensive care patients meeting the inclusion criteria. InterventionsControl patients received ward visits, three telephone calls at home, and clinic appointments at 8 wks and 6 months. Intervention patients received the same plus a 6-wk self-help rehabilitation manual. Measurements and Main ResultsWe measured levels of depression and anxiety (Hospital Anxiety and Depression Scale), phobic symptoms (Fear Index), posttraumatic stress disorder (PTSD)-related symptoms (Impact of Events Scale), and scores on the Short-Form Health Survey physical dimension 8 wks and 6 months after intensive care unit (ICU) treatment. Memory for ICU was assessed at 2 wks post-ICU discharge using the ICU Memory Tool.The intervention group improved, compared with the control patients, on the Short-Form Health Survey physical function scores at 8 wks and 6 months (p = .006), and there was a trend to a lower rate of depression at 8 wks (12% vs. 25%). However, there were no differences in levels of anxiety and PTSD-related symptoms between the groups. The presence of delusional memories was correlated significantly with both anxiety and Impact of Events Scale scores. ConclusionsA self-help rehabilitation manual is effective in aiding physical recovery and reducing depression. However, in those patients recalling delusional memories from the ICU, further psychological care may be needed to reduce the incidence of anxiety and PTSD-related symptoms.

Clinical Informatics in Critical Care

Health care information systems have the potential to enable better care of patients in much the same manner as the widespread use of the automobile and telephone did in the early 20th century. The car and phone were rapidly accepted and embraced throughout the world when these breakthroughs occurred. However, the automation of health care with use of computerized information systems has not been as widely accepted and implemented as computer technology use in all other sectors of the global economy. In this article, the authors examine the need, risks, and rewards of clinical informatics in health care as well as its specific relationship to critical care medicine.

A new device for the prevention of pulmonary embolism in critically ill patients: Results of the European Angel Catheter Registry.

BACKGROUND Pulmonary embolism (PE) is a potentially life-threatening complication of critical illness. In trauma and neurosurgical patients with contraindications to anticoagulation, inferior vena cava (IVC) filters have been used to prevent PE, but their associated long-term complication rates and difficulties associated with filter removal have limited their use. The Angel catheter is a temporary device, which combined an IVC filter with a triple-lumen central venous catheter (IVC filter–catheter) and is intended for bedside placement and removal when no longer indicated. METHODS This study presents data from a European Registry of 60 critically ill patients in whom the IVC filter–catheter was used to prevent PE. The patients were all at high risk of PE development or recurrence and had contraindications to anticoagulation. The primary end points of this study were to evaluate the safety (in particular, the presence of infectious or thrombotic events) and effectiveness (the numbers of PEs and averted PEs) of the IVC filter–catheter. RESULTS The main diagnosis before catheter insertion was major trauma in 33 patients (55%), intracerebral hemorrhage or stroke in 9 (15%), a venous thromboembolic event in 9 (15%), and active bleeding in 6 (10%). The IVC filter–catheter was placed as prophylaxis in 51 patients (85%) and as treatment in the 9 patients (15%) with venous thromboembolic event. The devices were inserted at the bedside without fluoroscopic guidance in 54 patients (90%) and within a median of 4 days after hospital admission. They were left in place for a mean of 6 days (4–8 days). One patient developed a PE, without hemodynamic compromise; two PEs were averted. No serious adverse events were reported. CONCLUSION Early bedside placement of an IVC filter–catheter is possible, and our results suggest that this is a safe, effective alternative to short-term PE prophylaxis for high-risk patients with contraindications to anticoagulation. LEVEL OF EVIDENCE Therapeutic study, level V.

Towards Standardisation of Drug Infusion Concentrations in UK Critical Care Units

There is wide variation in infusion practice in UK critical care units. Standardising infusion concentrations may lead to efficiency gains through reduced training burdens, common nomenclature, reductions in error rates and mass production of ready-to-use products by the pharmaceutical industry. A proposed list of standard concentrations for 20 medications given by infusion was produced. Critical care units were surveyed to assess the acceptability of the list for adoption as a national standard; 164 critical care units responded (63% of UK NHS trusts). High acceptance of the list has been shown, with the exception of concentrations of adrenaline, potassium and phosphate where further work is required. The proposed concentrations of the remaining 17 medications should be adopted as a national standard.

A Survey to Inform Standardisation of Intravenous Medication Concentrations in Critical Care

Introduction It is estimated that over 10% of hospital admissions in the United Kingdom (UK) involve an adverse event, over half of which are believed to be avoidable. Figures suggest that 10,784 medication errors occurred between April and June 2006, although the true figure is likely to be higher due to under reporting. Evidence that quantifies the magnitude of this type of error in the UK is scant, particularly in critical care. Reducing the incidence of preparation and administration errors is difficult. For example, discrepancies between prescribed and delivered opioid and catecholamine infusions are frequent. In one study, over 65% of opioid infusions were associated with more than 10% variation from the intended concentration and 6% of infusions involved two fold errors or greater. Catecholamine concentrations were also significantly different and there was a high degree of daily intra-patient variability, potentially contributing to haemodynamic instability.

Peri-operative care of elderly patients – an urgent need for change: a consensus statement to provide guidance for specialist and non-specialist anaesthetists

Aims and scope of the statement Compared to younger, fitter patients, elderly patients are at a disproportionately greater risk of avoidable morbidity and mortality. In this statement, we aim to give guidance on the role of anaesthetists in optimising care of elderly patients by discussing principles relevant to the whole care pathway. Elderly patients are a highly heterogeneous group, often frail with multiple comorbidities. Therefore, consideration throughout the care pathway must be given to elderly patients as individuals. We will emphasise that one of the best ways to optimise care during the perioperative period is to apply the core principles that have already been successfully applied to well-managed daycase care. We will also emphasise how best practice in anaesthesia for elderly patients aligns with enhanced recovery.

Critical Care Contingency Planning: Phased Responses and Triaging Framework

As most of our readers will be aware from previous publications and from the special articles contained in this edition, a lot of work has gone into highlighting the implications of an influenza pandemic for critical care services and trying to work out how to make the best use of the resources that may be available. The latest Department of Health Document ‘Pandemic influenza: surge capacity and prioritisation in health services – provisional UK guidance’ (available on the DH website) has made an encouraging start in providing official recognition of the problems likely to be encountered as a result of limited bed capacity, and also supports the concept that triaging decisions cannot be left to secondary care (and particularly critical care specialists) alone. Regrettably, however, even if its recommendations for patient selection are fully followed and the number of inappropriate referrals to critical care is reduced significantly, there is still a strong probability that during the peak of a pandemic the number of patients who are likely to benefit from critical care will still significantly exceed bed capacity – even if this is maximally expanded. In the original working of the Critical Care Contingency Planning Group a draft document on Phased Responses and Triaging was produced as a starter to addressing these difficulties. Further work on this was then put on-hold pending the production of official ethical guidance and other documentation to address these problems. However, now that these have been finalised and we still face potential dilemmas about how ICUs will be able to cope, feedback from critical care network discussions has persuaded us that it may be useful to circulate a revised version of this document, updated to include more recent recommendations, in the hope that this may be of help in assisting local planning. In particular, the document addresses two concepts that were initially felt to be inappropriate or unacceptable, but which now may be considered reasonable/realistic. These are the possibility of using some method of lottery selection if there are several appropriate referrals but insufficient bed numbers, and the fact that at some point there may be a requirement to accept temporary closure of intensive care to further referrals if no beds are available. It is hoped that consensus support for the principles of this document may help to produce reassurance for staff (with the support of local PCTs and Trust Management) that if potentially preventable deaths occur in such circumstances they will not be vulnerable to litigation or professional criticism when no other treatment options were available.

Management of the critically ill patient with severe acute pancreatitis

OBJECTIVE Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.

Obstetric early warning systems to prevent bad outcome.

Purpose of review Early warning scores, early warning systems and rapid response systems, were established in 1999. In the UK, a National Early Warning Score was launched in 2013 and is now used throughout the National Health Service. In 2007, a firm recommendation was made by the maternal confidential death enquiry that maternity units should incorporate a modified early obstetric warning score chart into clinical practice. Although there was enthusiastic uptake of this recommendation, local recording systems vary throughout the country and there is now a need to revisit revise and standardize an obstetric early warning system (ObsEWS). Recent project The intercollegiate Maternal Critical Care group of the Obstetric Anaesthetists’ Association have produced an ObsEWS in line with the aggregate UK National Early Warning Score. Six physiological parameters are incorporated: respiratory rate, oxygen saturations, temperature, systolic blood pressure, diastolic blood pressure, and pulse rate. However, robust physiological thresholds for the measured parameters are currently lacking but required for a more sensitive and specific ObsEWS. Summary A greater focus and study on the management of maternal morbidity (in addition to mortality data) and the development of better systems within and across the multidisciplinary team to detect early deterioration should improve management of serious illness in obstetrics. It is imperative that we undertake robust ObsEWS and data collection, including electronic systems with research and evidence-based recommendations to underpin this system. This should improve patient safety and result in more efficient, cost-effective management of sicker patients in our complex modern healthcare systems.

Excellent anaesthesia needs patient preparation and postoperative support to influence outcome.

Purpose of review Studies over many years have demonstrated that preoptimization and attention to appropriate perioperative care is associated with a substantial decrease in surgical mortality. This review discusses ways in which patient preparation and perioperative support can minimize surgical mortality and morbidity. Recent findings Scoring systems continue to be developed in order to classify categories of surgical risk. Objective physiologically based assessments can also identify high-risk groups of patients. Debate continues over the indications for specific interventions such as β-blockade or statin therapy. There is continuing interest in perioperative optimization of oxygen delivery. A multimodality approach paying attention to a range of possible interventions appears to be beneficial. Audit, training, experience and a sufficient volume of procedures are all factors associated with surgical mortality. Summary The provision of a high-quality service throughout the perioperative period is vital for a successful outcome. Patients need to be assessed well before major elective surgery to determine if they fall into a high-risk category. Some patients may benefit from a change in management. Postoperatively, critical-care support should be available backed by level 1 (enhanced ward) care with input from outreach or medical emergency teams 24 hours per day, seven days a week.