V S Barber

Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation

Abstract Objective To compare outcomes in critically ill patients undergoing artificial ventilation who received a tracheostomy early or late in their treatment. Data sources The Cochrane Central Register of Clinical Trials, Medline, Embase, CINAHL, the National Research Register, the NHS Trusts Clinical Trials Register, the Medical Research Council UK database, the NHS Research and Development Health Technology Assessment Programme, the British Heart Foundation database, citation review of relevant primary and review articles, and expert informants. Study selection Randomised and quasi-randomised controlled studies that compared early tracheostomy with either late tracheostomy or prolonged endotracheal intubation. From 15 950 articles screened, 12 were identified as “randomised or quasi-randomised” controlled trials, and five were included for data extraction. Data extraction Five studies with 406 participants were analysed. Descriptive and outcome data were extracted. The main outcome measure was mortality in hospital. The incidence of hospital acquired pneumonia, length of stay in a critical care unit, and duration of artificial ventilation were also recorded. Random effects meta-analyses were performed. Results Early tracheostomy did not significantly alter mortality (relative risk 0.79, 95% confidence interval 0.45 to 1.39). The risk of pneumonia was also unaltered by the timing of tracheostomy (0.90, 0.66 to 1.21). Early tracheostomy significantly reduced duration of artificial ventilation (weighted mean difference –8.5 days, 95% confidence interval –15.3 to –1.7) and length of stay in intensive care (–15.3 days, –24.6 to –6.1). Conclusions In critically ill adult patients who require prolonged mechanical ventilation, performing a tracheostomy at an earlier stage than is currently practised may shorten the duration of artificial ventilation and length of stay in intensive care.

Modifiable factors influencing relatives' decision to offer organ donation: systematic review.

Objective To identify modifiable factors that influence relatives’ decision to allow organ donation. Design Systematic review. Data sources Medline, Embase, and CINAHL, without language restriction, searched to April 2008. Review methods Three authors independently assessed the eligibility of the identified studies. We excluded studies that examined only factors affecting consent that could not be altered, such as donor ethnicity. We extracted quantitative results to an electronic database. For data synthesis, we summarised the results of studies comparing similar themes. Results We included 20 observational studies and audits. There were no randomised controlled trials. The main factors associated with reduced rates of refusal were the provision of adequate information on the process of organ donation and its benefits; high quality of care of potential organ donors; ensuring relatives had a clear understanding of brain stem death; separating the request for organ donation from notification that the patient had died; making the request in a private setting; and using trained and experienced individuals to make the request. Conclusions Limited evidence suggests that there are modifiable factors in the process of requests for organ donation, in particular the skills of the individual making the request and the timing of this conversation, that might have a significant impact on rates of consent. Targeting these factors might have a greater and more immediate effect on the number of organs for donation than legislative or other long term strategies.

A national survey of intensive care follow-up clinics

Intensive care follow‐up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow‐up clinics in the UK is unknown. We performed a survey of intensive care follow‐up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow‐up clinics and details of current follow‐up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow‐up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow‐up clinic, 158 (88%) cited ‘financial constraints’ as the reason. Over half of the follow‐up clinics (44 clinics, 55%) were nurse‐led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow‐up clinics (39 clinics, 49%) have pre‐negotiated access to at least one other out‐patient service.

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients.

We conducted a randomised controlled trial of mandated five‐channel physiological monitoring vs standard care, in acute medical and surgical wards in a single UK teaching hospital. In all, 402 high‐risk medical and surgical patients were studied. The primary outcome was the proportion of patients experiencing one or more major adverse events, including urgent staff calls, changes to higher care levels, cardiac arrests or death, in 96 h following randomisation. Secondary outcomes were the proportion of patients requiring acute treatment changes, and the 30‐day and hospital mortality. In the 96 h following randomisation, 113 (56%) patients in the monitored arm and 116 (58%) in the control arm (OR 0.94, 95% CI 0.63–1.40, p = 0.76) had a major event. An acute change in treatment was necessary in 107 (53%) monitored patients and 101 (50%) control patients (OR 0.55, 95% CI 0.87–1.29). Thirty‐four (17%) monitored patients and 35 (17%) control patients died within 30 days. Thirteen patients in the control group received full five‐channel monitoring at the request of the ward staff. We conclude that mandated electronic vital signs monitoring in high risk medical and surgical patients has no effect on adverse events or mortality.

A national survey of the management of delirium in UK intensive care units.

BACKGROUND Delirium is an acute organ dysfunction common amongst patients treated in intensive care units. The associated morbidity and mortality are known to be substantial. Previous surveys have described which screening tools are used to diagnose delirium and which medications are used to treat delirium, but these data are not available for the United Kingdom. AIM This survey aimed to describe the UK management of delirium by consultant intensivists. Additionally, knowledge and attitudes towards management of delirium were sought. The results will inform future research in this area. METHODS A national postal survey of members of the UK Intensive Care Society was performed. A concise two page questionnaire survey was sent, with a second round of surveys sent to non-respondents after 6 weeks. The questionnaire was in tick-box format. RESULTS Six hundred and eighty-one replies were received from 1308 questionnaires sent, giving a response rate of 52%. Twenty-five percent of respondents routinely screen for delirium, but of these only 55% use a screening tool validated for use in intensive care. The majority (80%) of those using a validated instrument used the Confusion Assessment Method for the Intensive Care Unit. Hyperactive delirium is treated pharmacologically by 95%; hypoactive delirium is treated pharmacologically by 25%, with haloperidol the most common agent used in both. Over 80% of respondents agreed that delirium prolongs mechanical ventilation and hospital stay and requires active treatment. CONCLUSION This UK survey demonstrates screening for delirium is sporadic. Pharmacological treatment is usually with haloperidol in spite of the limited evidence to support this practice. Hypoactive delirium is infrequently treated pharmacologically.

Use of helium-oxygen mixture in adult patients presenting with exacerbations of asthma and chronic obstructive pulmonary disease: a systematic review.

We examined systematically all controlled and cross‐over randomised trials in patients with acute exacerbations of asthma and chronic obstructive pulmonary disease comparing Heliox against air‐oxygen mixtures. Fourteen studies were identified. In asthma studies, peak expiratory flow rate (PEFR) was increased by an average of 29.6% (95% CI 16.6–42.6) by Heliox‐driven nebulisers, or by 13.3 l.min−1 (95% CI 3.71–22.81) absolute. In studies of patients with chronic obstructive pulmonary disease receiving non‐invasive ventilation the arterial carbon dioxide tension (Paco2) and respiratory rate were unchanged: weighted mean difference for Paco2−0.29kPa (95% CI − 0.64–0.07) favoured Heliox, and for respiratory rate 1.6 breaths.min−1 (95% CI − 0.93, 4.14) favoured control. Heliox minimally reduced the work of breathing in intubated patients, and reduced intrinsic positive end expiratory pressure (iPEEP). The use of Heliox to drive nebulisers in patients with acute asthma slightly improves airflow measures. We were unable to determine whether this improved recovery.

Strict glucose control in the critically ill.

May not be such a good thing for all critically ill patients

A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children.

The laryngeal mask airway is included as a first line airway device during adult resuscitation by first responders. However, there is little evidence for its role in paediatric resuscitation. Using anaesthetised children as a model for paediatric cardiopulmonary arrest, we compared the ability of critical care nurses to manually ventilate the anaesthetised child via the laryngeal mask airway compared with the facemask and oropharyngeal airway. The airway devices were inserted in random order and chest expansion was measured using an ultrasound distance transducer. The critical care nurses were able to place the laryngeal mask airway and achieve successful ventilation in 82% of children compared to 70% using the facemask and oropharyngeal airway, although the difference was not statistically significant (p = 0.136). The median time to first successful breath using the laryngeal mask airway was 39 s compared to 25 s using the facemask (p < 0.001). In this group of nurses, we did not show a difference in ventilation via a laryngeal mask airway or facemask, although facemask ventilation was achieved more quickly.

A comparison of the laryngeal mask airway with the facemask and oropharyngeal airway for manual ventilation by first responders in children

In adults, first responders to a cardiopulmonary arrest provide better ventilation using a laryngeal mask airway than a facemask. It is unclear if the same is true in children. We investigated this by comparing the ability of 36 paediatric ward nurses to ventilate the lungs of 99 anaesthetised children (a model for cardiopulmonary arrest) using a laryngeal mask airway and using a facemask with an oropharyngeal airway. Anteroposterior chest wall displacement was measured using an ultrasonic detector. Nurses achieved successful ventilation in 74 (75%) of cases with the laryngeal mask airway and 76 (77%) with facemask and oropharyngeal airway (p = 0.89). Median (IQR [range]) time to first breath was longer for the laryngeal mask airway (48 (39–65 [8–149])) s than the facemask/airway (35 (25–53 [14–120]) s; p < 0.0001). In 10 cases (10%) the lungs were ventilated using the laryngeal mask airway but not using the facemask/oropharyngeal airway. We conclude that ventilation is achieved rapidly using a facemask and oropharyngeal airway, and that the laryngeal mask airway may represent a useful second line option for first responders.

Study protocol: The Intensive Care Outcome Network ('ICON') study

BackgroundExtended follow-up of survivors of ICU treatment has shown many patients suffer long-term physical and psychological consequences that affect their health-related quality of life. The current lack of rigorous longitudinal studies means that the true prevalence of these physical and psychological problems remains undetermined.Methods/DesignThe ICON (Intensive Care Outcome Network) study is a multi-centre, longitudinal study of survivors of critical illness. Patients will be recruited prior to hospital discharge from 20–30 ICUs in the UK and will be assessed at 3, 6, and 12 months following ICU discharge for health-related quality of life as measured by the Short Form-36 (SF-36) and the EuroQoL (EQ-5D); anxiety and depression as measured by the Hospital Anxiety and Depression Scale (HADS); and post traumatic stress disorder (PTSD) symptoms as measured by the PTSD Civilian Checklist (PCL-C). Postal questionnaires will be used.DiscussionThe ICON study will create a valuable UK database detailing the prevalence of physical and psychological morbidity experienced by patients as they recover from critical illness. Knowledge of the prevalence of physical and psychological morbidity in ICU survivors is important because research to generate models of causality, prognosis and treatment effects is dependent on accurate determination of prevalence. The results will also inform economic modelling of the long-term burden of critical illness.Trial RegistrationISRCTN69112866