Objectives: The association between hyperlactatemia and adverse outcome in patients admitted to ICUs following gastrointestinal surgery has not been reported. To explore the hypothesis that in a large cohort of gastrointestinal surgical patients, the peak serum lactate (in the first 24 hr) observed in patients admitted to ICU following surgery is associated with unadjusted and severity-adjusted acute hospital mortality and that the strength of association is greater in patients admitted following ?emergency? surgery than in patients admitted following ?elective? surgery. Design: A retrospective cohort study of all patients who had gastrointestinal surgery and were admitted directly to the ICU between 2008 and 2012. Setting: Two hundred forty-nine hospitals in the United Kingdom. Patients: One hundred twenty-one thousand nine hundred ninety patients. Interventions: None. Measurements and Main Results: Peak blood lactate in the first 24 hours of admission to critical care, acute hospital mortality, length of stay, and other variables routinely collected within the U.K. Intensive Care National Audit and Research Centre Case Mix Programme database. Elevated blood lactate was associated with increased risk of death and prolonged duration of stay, and the relationship was maintained once adjusted for confounding variables. The positive association between mortality and levels of blood lactate continued down into the ?normal range,? without evidence of a plateau. There was no difference in the extent to which hyperlactatemia was related to mortality between patients admitted following elective and emergency surgery. Conclusions: These findings have implications for our understanding of the role of lactate in critically ill patients.
Davidson AC, Banham S, Elliott M, Kennedy D, Gelder C, Glossop A, Church AC, Creagh-Brown B, Dodd JW, Felton T, Foex B, Mansfield L, McDonnell L, Parker R, Patterson CM, Sovani M, Thomas L (2016) BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults,THORAX71pp. 1-35 BMJ PUBLISHING GROUP
Background The work demands of critical care can be a major cause of stress in intensive care unit (ICU) professionals and lead to poor health outcomes. In the process of recovery from work, psychological rumination is considered to be an important mediating variable in the relationship between work demands and health outcomes. This study aimed to extend our knowledge of the process by which ICU stressors and differing rumination styles are associated with burnout, depression and risk of psychiatric morbidity among ICU professionals. Methods Ninety-six healthcare professionals (58 doctors and 38 nurses) who work in ICUs in the UK completed a questionnaire on ICU-related stressors, burnout, work-related rumination, depression and risk of psychiatric morbidity. Results Significant associations between ICU stressors, affective rumination, burnout, depression and risk of psychiatric morbidity were found. Longer working hours were also related to increased ICU stressors. Affective rumination (but not problem-solving pondering or distraction detachment) mediated the relationship between ICU stressors, burnout, depression and risk of psychiatric morbidity, such that increased ICU stressors, and greater affective rumination, were associated with greater burnout, depression and risk of psychiatric morbidity. No moderating effects were observed. Conclusions Longer working hours were associated with increased ICU stressors, and increased ICU stressors conferred greater burnout, depression and risk of psychiatric morbidity via increased affective rumination. The importance of screening healthcare practitioners within intensive care for depression, burnout and psychiatric morbidity has been highlighted. Future research should evaluate psychological interventions which target rumination style and could be made available to those at highest risk. The efficacy and cost effectiveness of delivering these interventions should also be considered.
Tyson Emma, Creagh-Brown Ben (2018) Postoperative care,Medicine (United Kingdom)46(12)pp. 750-753 Elsevier
Optimal postoperative care involves a multidisciplinary team of healthcare professionals and a patient-centred approach to avoid postoperative complications and enable a rapid return to normal function. During the last decade, enhanced recovery after surgery programmes have been implemented worldwide to reduce complications and length of stay ? challenging traditional models of perioperative care. Some aspects of perioperative care have consensus guidelines without significant controversy, whereas others, such as perioperative fluid therapy, remain contentious.
Abbott T.E.F., Fowler A.J., Pelosi P., Gama de Abreu M., Møller A.M., Canet J., Creagh-Brown B., Mythen M., Gin T., Lalu M.M., Futier E., Grocott M.P., Schultz M.J., Pearse R.M., Myles P., Gan T.J., Kurz A., Peyton P., Sessler D., Tramèr M., Cyna A., De Oliveira G.S., Wu C., Jensen M., Kehlet H., Botti M., Boney O., Haller G., Cook T., Fleisher L., Neuman M., Story D., Gruen R., Bampoe S., Evered L., Scott D., Silbert B., van Dijk D., Kalkman C., Chan M., Grocott H., Eckenhoff R., Rasmussen L., Eriksson L., Beattie S., Wijeysundera D., Landoni G., Leslie K., Biccard B., Howell S., Nagele P., Richards T., Lamy A., Gabreu M., Klein A., Corcoran T., Jamie Cooper D., Dieleman S., Diouf E., McIlroy D., Bellomo R., Shaw A., Prowle J., Karkouti K., Billings J., Mazer D., Jayarajah M., Murphy M., Bartoszko J., Sneyd R., Morris S., George R., Moonesinghe R., Shulman M., Lane-Fall M., Nilsson U., Stevenson N., van Klei W., Cabrini L., Miller T., Pace N., Jackson S., Buggy D., Short T., Riedel B., Gottumukkala V., Alkhaffaf B., Johnson M. (2018) A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications,British Journal of Anaesthesia120(5)pp. 1066-1079 Elsevier
Background
There is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research.
Methods
A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three-stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials.
Results
From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions); (ii) pneumonia (12 definitions); and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition.
Conclusions
A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.
The results section of this abstract should read:
Results A total of 369 patients were referred over the 6 year period. Of these, 194 (52.6%) were admitted. The largest outcome group was total liberation from all forms of MV (45%). The remainder were shown to (1) require nocturnal non-invasive ventilation (NIV) (21%); (2) require nocturnal and intermittent daytime NIV (1%); (3) require long-term tracheostomy ventilation (19%); and (4) died in hospital (15%). Post-surgical and COPD patients had the highest rate of total liberation from mechanical ventilation at 60% and 54%, respectively. The median time from admission to tracheostomy decannulation was 18 days (9?33). NMD-CWD patients had the lowest hospital mortality (7%), whereas COPD patients had the highest hospital mortality (29%). The overall survival at 12 and 24 months was 55% and 47%, respectively. 25% of the COPD patients were alive and 59% of the NMD-CWD patients were alive at 24 months (Figure 1).
Background
The work demands of critical care can be a major cause of stress in intensive care unit (ICU) professionals and lead to poor health outcomes. In the process of recovery from work, psychological rumination is considered to be an important mediating variable in the relationship between work demands and health outcomes. This study aimed to extend our knowledge of the process by which ICU stressors and differing rumination styles are associated with burnout, depression and risk of psychiatric morbidity among ICU professionals.
Methods
Ninety-six healthcare professionals (58 doctors and 38 nurses) who work in ICUs in the UK completed a questionnaire on ICU-related stressors, burnout, work-related rumination, depression and risk of psychiatric morbidity.
Results
Significant associations between ICU stressors, affective rumination, burnout, depression and risk of psychiatric morbidity were found. Longer working hours were also related to increased ICU stressors. Affective rumination (but not problem-solving pondering or distraction detachment) mediated the relationship between ICU stressors, burnout, depression and risk of psychiatric morbidity, such that increased ICU stressors, and greater affective rumination, were associated with greater burnout, depression and risk of psychiatric morbidity. No moderating effects were observed.
Conclusions
Longer working hours were associated with increased ICU stressors, and increased ICU stressors conferred greater burnout, depression and risk of psychiatric morbidity via increased affective rumination. The importance of screening healthcare practitioners within intensive care for depression, burnout and psychiatric morbidity has been highlighted. Future research should evaluate psychological interventions which target rumination style and could be made available to those at highest risk. The efficacy and cost effectiveness of delivering these interventions should also be considered.
A 59-year-old man was diagnosed with a massive pulmonary embolism. Despite thrombolysis there were two episodes of cardiac arrest and following recovery of spontaneous circulation profound cardiorespiratory failure ensued. An extracorporeal membrane oxygenation retrieval team initiated veno-venous extracorporeal membrane oxygenation on site to facilitate transfer to the extracorporeal membrane oxygenation centre. An excellent outcome is reported in the short term. This represents one of the few published cases of veno-venous extracorporeal membrane oxygenation for a massive pulmonary embolism following thrombolysis.
Background and Objective: Obesity is an important contributor to the risk of both asthma and Type 2 Diabetes (T2DM). However, it has been suggested that T2DM and asthma are also independently associated. The aim of this systematic review was to synthesize the evidence for an independent relationship between T2DM and asthma.
Methods: MEDLINE and EMBASE were searched for studies reporting the relationship between asthma and T2DM in adults. Given a potential bidirectional relationship, articles relating to T2DM as a risk factor for asthma, and asthma as a risk factor for T2DM were examined separately.
Results: Eight studies were identified for inclusion in the review (n=2,934,399 participants). Four studies examined incident diabetes in those with asthma. The pooled (random effects model) adjusted hazard ratio for incident T2DM in asthma was 1.37 (95%CI 1.12-1.69; p Â0.001) after controlling for BMI.
Four studies reported prevalence or incidence rates of asthma in people with T2DM; higher rates of asthma in those with T2DM were reported in all four studies. Meta-analysis of results was not possible due to methodological heterogeneity.
The quality of included studies was good, but due to small numbers, publication bias cannot be excluded.
Conclusion: The published literature suggests a bidirectional independent relationship between T2DM and asthma, although we cannot exclude publication bias.
Background
Chronic obstructive pulmonary disease (COPD) and type 2 diabetes (T2DM) are common comorbidities. COPD is a known risk factor for incident T2DM, however few studies have examined the relationship in reverse. The primary aim of this study was to compare the incidence of COPD in people with and without T2DM.
Materials and methods
We conducted a retrospective case-control study using a long-established English general practice network database (n = 894,646). We matched 29,217 cases of T2DM with controls, adjusting for age, gender, smoking status, BMI and social deprivation, to achieve 1:1 propensity matching and compared the rate of incident COPD over eight years of follow-up. We performed a secondary analysis to investigate the effect of insulin, metformin and sulphonylureas on COPD incidence.
Results
People with T2DM had a reduced risk of COPD compared to matched controls over the follow-up period (HR 0.89, 95%CI 0.79?0.93). 48.5% of those with T2DM were ex-smokers compared with 27.3% of those without T2DM. Active smoking rates were 20.4% and 23.7% respectively. Insulin, metformin and sulphonylureas were not associated with incident COPD.
Conclusions
People with T2DM are less likely to be diagnosed with COPD than matched controls. This may be due to positive lifestyle changes, such as smoking cessation in those with T2DM.
Bonnici Denise Mifsud, Sanctuary Thomas, Warren Alex, Murphy Patrick B, Steier Jorge, Marino Philip, Pattani Hina, Creagh-Brown Ben C, Hart Nicholas (2016) Prospective observational cohort study of patients with weaning failure admitted to a specialist weaning, rehabilitation and home mechanical ventilation centre,BMJ Open6(3)e010025 BMJ Publishing Group
Objectives According to National Health Service England (NHSE) specialist respiratory commissioning specification for complex home ventilation, patients with weaning failure should be referred to a specialist centre. However, there are limited data reporting the clinical outcomes from such centres.
Setting Prospective observational cohort study of patients admitted to a UK specialist weaning, rehabilitation and home mechanical ventilation centre between February 2005 and July 2013.
Participants 262 patients admitted with a median age of 64.2?years (IQR 52.6?73.2?years). 59.9% were male.
Results 39.7% of patients had neuromuscular and/or chest wall disease, 21% were postsurgical, 19.5% had chronic obstructive pulmonary disease (COPD), 5.3% had obesity-related respiratory failure and 14.5% had other diagnoses. 64.1% of patients were successfully weaned, with 38.2% weaned fully from ventilation, 24% weaned to nocturnal non-invasive ventilation (NIV), 1.9% weaned to nocturnal NIV with intermittent NIV during the daytime. 21.4% of patients were discharged on long-term tracheostomy ventilation. The obesity-related respiratory failure group were most likely to wean (relative risk (RR) for weaning success=1.48, 95% CI 1.35 to 1.77; pÂ0.001), but otherwise weaning success rates did not significantly vary by diagnostic group. The median time-to-wean was 19?days (IQR 9?33) and the median duration of stay was 31?days (IQR 16?50), with no difference observed between the groups. Weaning centre mortality was 14.5%, highest in the COPD group (RR=2.15, 95% CI 1.19 to 3.91, p=0.012) and lowest in the neuromuscular and/or chest wall disease group (RR=0.34, 95% CI 0.16 to 0.75, p=0.007). Of all patients discharged alive, survival was 71.7% at 6?months and 61.8% at 12?months postdischarge.
Conclusions Following NHSE guidance, patients with weaning delay and failure should be considered for transfer to a specialist centre where available, which can demonstrate favourable short-term and long-term clinical outcomes.
Objectives:
The association between hyperlactatemia and adverse outcome in patients admitted to ICUs following gastrointestinal surgery has not been reported. To explore the hypothesis that in a large cohort of gastrointestinal surgical patients, the peak serum lactate (in the first 24 hr) observed in patients admitted to ICU following surgery is associated with unadjusted and severity-adjusted acute hospital mortality and that the strength of association is greater in patients admitted following ?emergency? surgery than in patients admitted following ?elective? surgery.
Design:
A retrospective cohort study of all patients who had gastrointestinal surgery and were admitted directly to the ICU between 2008 and 2012.
Setting:
Two hundred forty-nine hospitals in the United Kingdom.
Patients:
One hundred twenty-one thousand nine hundred ninety patients.
Interventions:
None.
Measurements and Main Results:
Peak blood lactate in the first 24 hours of admission to critical care, acute hospital mortality, length of stay, and other variables routinely collected within the U.K. Intensive Care National Audit and Research Centre Case Mix Programme database. Elevated blood lactate was associated with increased risk of death and prolonged duration of stay, and the relationship was maintained once adjusted for confounding variables. The positive association between mortality and levels of blood lactate continued down into the ?normal range,? without evidence of a plateau. There was no difference in the extent to which hyperlactatemia was related to mortality between patients admitted following elective and emergency surgery.
Conclusions:
These findings have implications for our understanding of the role of lactate in critically ill patients.
Buggy D.J., Freeman J., Johnson M.Z., Leslie K., Riedel B., Sessler D.I., Kurz A., Gottumukkala V., Short T., Pace N., Myles P.M., Gan T.J., Peyton P., Tramèr M., Cyna A., De Oliveira G.S., Wu C., Jensen M., Kehlet H., Botti M., Boney O., Haller G., Grocott M., Cook T., Fleisher L., Neuman M., Story D., Gruen R., Bampoe S., Evered L., Scott D., Silbert B., van Dijk D., Kalkman C., Chan M., Grocott H., Eckenhoff R., Rasmussen L., Eriksson L., Beattie S., Wijeysundera D., Landoni G., Biccard B., Howell S., Nagele P., Richards T., Lamy A., Lalu M., Pearse R., Mythen M., Canet J., Moller A., Gin T., Schultz M., Pelosi P., Gabreu M., Futier E., Creagh-Brown B., Abbott T., Klein A., Corcoran T., Jamie Cooper D., Dieleman S., Diouf E., McIlroy D., Bellomo R., Shaw A., Prowle J., Karkouti K., Billings J., Mazer D., Jayarajah M., Murphy M., Bartoszko J., Sneyd R., Morris S., George R., Moonesinghe R., Shulman M., Lane-Fall M., Nilsson U., Stevenson N., van Klei W., Cabrini L., Miller T., Jackson S., Alkhaffaf B. (2018) Systematic review and consensus definitions for standardised endpoints in perioperative medicine: postoperative cancer outcomes,British Journal of Anaesthesia121(1)pp. 38-44 Elsevier
Background
The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance.
Methods
We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician?researchers was then used to refine a recommended list of endpoints.
Results
We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by e70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival).
Conclusion
Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia?analgesia technique on oncological outcomes.
The report and description of the issue of factitious disorder
(formerly known as Munchausen?s syndrome) was
interesting and informative.1 The patient described presented
with features of acute severe asthma but this diagnosis was
discounted when more information became available. Another
mimic of acute severe asthma deserves mention in this context ? a condition commonly known as vocal cord dysfunction (VCD)
but perhaps more accurately termed paradoxical vocal fold
motion (PVFM)2 and historically termed Munchausen?s stridor.3
It is characterised by episodic unintentional paradoxical
adduction of the vocal cords (or other laryngeal structures),
resulting in upper airway obstruction. Patients may experience a variety of symptoms including dyspnoea, cough, stridor,
wheezing, neck tightness and voice changes. These symptoms
are often precipitated by physical activity and intense emotion.
Presentation may be dramatic and can be mistaken for acute
asthma, anaphylaxis or angioedema.
Respiratory failure is a common complication of acute cardiorespiratory disease and exacerbations of chronic respiratory disease. It can be a feature of advanced chronic cardiac, respiratory and neurological diseases. Respiratory failure can manifest as hypoxaemia, hypercapnia or both. This article reviews the pathophysiology of these perturbations in respiratory homeostasis, the clinical features of acute and chronic respiratory failure and a brief discussion of the management.
This study investigated how intensivists make decisions regarding withholding and withdrawing treatment for patients at the end of their lives. This involved completing in-depth interviews from two sites of the South of England, United Kingdom by twelve intensivists. The data collected by these intensivists were analysed using thematic analysis. This resulted in the identification of three themes: intensivists? role, treatment effectiveness, and patients? best interest. Transcending these were two overarching themes relating to the balance between quantity and quality of life, and the intensivists? sense of responsibility versus burden. The results are considered in terms of making sense of death and the role of beliefs in the decision-making process.
Williams and Oakeshott caution against the use of the ² blocker bisoprolol for chronic heart failure in patients with severe asthma or chronic obstructive pulmonary disease (COPD).1 This recommendation is somewhat contentious. Patients with COPD often have cardiac comorbidities, including chronic heart failure (~20% of patients2), and in one large study of patients with COPD, 27% of deaths were attributable to cardiac causes.3 Selective ² blockers such as bisoprolol have been shown to be safe in COPD.4 5 Moreover, in addition to the beneficial effects on outcomes relating to heart failure, there is mounting evidence that ² blockade may also improve outcomes from COPD.6
Barnes J., Hunter J., Harris S., Shankar-Hari M., Diouf E., Jammer I., Kalkman C., Klein A.A., Corcoran T., Dieleman S., Grocott M.P.W., Mythen M.G., Myles P., Gan T.J., Kurz A., Peyton P., Sessler D., Tramèr M., Cyna A., De Oliveira G.S., Wu C., Jensen M., Kehlet H., Botti M., Boney O., Haller G., Grocott M., Cook T., Fleisher L., Neuman M., Story D., Gruen R., Bampoe S., Evered L., Scott D., Silbert B., van Dijk D., Chan M., Grocott H., Eckenhoff R., Rasmussen L., Eriksson L., Beattie S., Wijeysundera D., Landoni G., Leslie K., Biccard B., Howell S., Nagele P., Richards T., Lamy A., Lalu M., Pearse R., Mythen M., Canet J., Moller A., Gin T., Schultz M., Pelosi P., Gabreu M., Futier E., Creagh-Brown Ben, Fowler A., Abbott T., Klein A., Cooper D.J., McIlroy D., Bellomo R., Shaw A., Prowle J., Karkouti K., Billings J., Mazer D., Jayarajah M., Murphy M., Bartoszko J., Sneyd R., Morris S., George R., Moonesinghe R., Shulman M., Lane-Fall M., Nilsson U., Stevenson N., Cooper J.D., van Klei W., Cabrini L., Miller T., Pace N., Jackson S., Buggy D., Short T., Riedel B., Gottumukkala V., Alkhaffaf B., Johnson M. (2019) Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: infection and sepsis,British Journal of Anaesthesia122(4)pp. 500-508 Elsevier
Background:
Perioperative infection and sepsis are of fundamental concern to perioperative clinicians. However, standardised endpoints are either poorly defined or not routinely implemented. The Standardised Endpoints in Perioperative Medicine (StEP) initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials.
Methods:
We undertook a systematic review to identify measures of infection and sepsis used in the perioperative literature. A multi-round Delphi consensus process that included more than 60 clinician researchers was then used to refine a recommended list of outcome measures.
Results:
A literature search yielded 1857 titles of which 255 met inclusion criteria for endpoint extraction. A long list of endpoints, with definitions and timescales, was generated and those potentially relevant to infection and sepsis circulated to the theme subgroup and then the wider StEP-COMPAC working group, undergoing a three-stage Delphi process. The response rates for Delphi rounds 1, 3, and 3 were 89% (n=8), 67% (n=62), and 80% (n=8), respectively. A set of 13 endpoints including fever, surgical site, and organ-specific infections as defined by the US Centres for Disease Control and Sepsis-3 are proposed for future use.
Conclusions:
We defined a consensus list of standardised endpoints related to infection and sepsis for perioperative trials using an established and rigorous approach. Each endpoint was evaluated with respect to validity, reliability, feasibility, and patient centredness. One or more of these should be considered for inclusion in future perioperative clinical trials assessing infection, sepsis, or both, thereby permitting synthesis and comparison of future results.
Davidson C., Banham S., Elliott M., Kennedy D., Gelder C., Glossop A., Church C., Creagh-Brown Ben, Dodd J., Felton T., Foëx B., Mansfield L., McDonnell L., Parker R., Patterson C., Sovani M., Thomas L. (2016) British thoracic society/intensive care society guideline for the ventilatory management of acute hypercapnic respiratory failure in adults,BMJ Open Respiratory Research3(1)e000133pp. 1-11 BMJ Publishing Group
The British Thoracic Society (BTS) published the guideline ?The use of non-invasive ventilation in acute respiratory failure? in 2002.1 This was in response to trials that had demonstrated that non-invasive ventilation (NIV) was an alternative to invasive mechanical ventilation (IMV) in life-threatening respiratory acidosis due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). It drew attention to evidence that, when NIV was used in the less severely unwell patient, it also limited progression to more severe respiratory failure.2 The trial also demonstrated the feasibility, of delivering NIV on general medical or admission wards that had enhanced support and when staff were provided with ongoing training.
Background
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality in England, however estimates of its prevalence vary considerably. Routinely collected and coded primary care data can be used to monitor disease prevalence, however reliance upon diagnostic codes alone is likely to miss cases.
Methods
We devised an ontological approach to COPD case detection and implemented it in a large primary care database to identify definite and probable cases of COPD. We used this to estimate the prevalence of COPD in England.
Results
Use of this approach to detect definite COPD cases yielded a prevalence of 2.57% (95% CI 2.55?2.60) in the total population, 4.56% (95%CI 4.52?4.61) in those aged e 35 and 5.41% (95% CI 5.36?5.47) in ex or current smokers. The ontological approach identified an additional 10,543 definite cases compared with using diagnostic codes alone. Prevalence estimates were higher than the 1.9% prevalence currently reported by the UK primary care pay for performance (P4P) disease register.
COPD prevalence when definite and probable cases were combined was 3.02% (95% CI 3.0?3.05) in the total population, 5.38% (95% CI 5.33?5.42) in those aged e 35 and 6.46% (95% CI 6.46-6.40-6.56) in ex or current smokers.
Conclusions
We demonstrate a robust reproducible method for COPD case detection in routinely collected primary care data. Our calculated prevalence differed significantly from current estimates based upon P4P data, suggesting that the burden of COPD in England is greater than currently predicted.
Over the past three decades, experimental studies have contributed substantially to an
increased understanding of the pathogenesis of acute lung injury (ALI) and its extreme
manifestation, the acute respiratory distress syndrome (ARDS). However, many investigators have employed animal models that fail to accurately reproduce the heterogeneity
of human ALI/ARDS, and which are difficult to sustain for the protracted periods needed
to permit an assessment of the effects of mechanical ventilation and other supportive
measures upon the evolution of the syndrome. Clinical studies are therefore critical to
expanding our understanding of ALI/ARDS, and those that have contributed significantly
to progress in this area are summarized herein. Trials of putative treatment strategies
for ALI/ARDS are discussed elsewhere. For brevity, the abbreviation ALI is employed
throughout, unless studies were performed specifically in patients with ARDS.
Davies M., Allen M., Bentley A., Bourke S.C., Creagh-Brown Ben, D'Oliveiro R., Glossop A., Gray A., Jacobs P., Mahadeva R., Moses R., Setchfield I. (2018) British Thoracic Society Quality Standards for acute non-invasive ventilation in adults,BMJ Open Respiratory Research5(1)e000283pp. 1-13 BMJ Publishing Group
Introduction The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for the provision of acute non-invasive ventilation in adults together with measurable markers of good practice. Methods Development of British Thoracic Society (BTS) Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards. Results 6 quality statements have been developed, each describing a standard of care for the provision of acute non-invasive ventilation in the UK, together with measurable markers of good practice. Conclusion BTS Quality Standards for acute non-invasive ventilation in adults form a key part of the range of supporting materials that the Society produces to assist in the dissemination and implementation of guideline's recommendations.
Pulmonary veno-occlusive disease (PVOD) is a disorder which causes progressive pulmonary hypertension, usually presenting with worsening dyspnoea and right heart failure. Pulmonary oedema induced by pulmonary vasodilator therapy to reduce pulmonary arterial pressure has been well described in PVOD, but here we describe a case of PVOD presenting with recurrent episodes of acute non-cardiogenic pulmonary oedema, in the absence of significant pulmonary hypertension. Concern over the risk of precipitating pulmonary oedema led us to use inhaled nitric oxide to predict the safety and efficacy of sildenafil.
The aim of perioperative haemodilution is to reduce loss of red blood cells during elective surgery. The oncotic and molecular characteristics of the various plasma substitutes employed determine how effectively normovolaemia is maintained, and their non-oncotic effects include alterations in microvascular perfusion. In the previous issue of Critical Care, Martini and colleagues assessed the effects of haemodilution with either polyethylene glycol (PEG)ylated albumin or a commercially available hydroxyethyl starch-based colloid in a hamster haemorrhage model. PEGylated albumin was superior to hydroxyethyl starch, as reflected by survival, haemodynamic parameters and assessment of the microcirculation using intravital microscopy. © 2008 BioMed Central Ltd.
A 37 yr old lady in her 14th week of her second pregnancy presented to chest clinic with breathlessness. Over the preceding month she had gradual onset of exertional breathlessness limiting her activities of daily living. Examination and routine blood tests were unremarkable and she declined a chest radiograph. Her symptoms progressed and she allowed us to perform a chest radiograph, which revealed a large right sided pneumothorax. This was aspirated successfully. During the final few months of her pregnancy she had a further episode of symptomatic ipsalateral pneumothorax, which was treated successfully with aspiration. She delivered a healthy baby via uncomplicated caesarean section under a spinal anaesthetic at term. A chest radiograph taken 2 d post-partum showed normal lung fields with no pneumothorax. Unfortunately, 2 weeks later she developed her third ipsalateral pneumothorax and this was treated conservatively pending video-assisted thoracoscopic surgery and pleurodesis, which occurred a few weeks later. At VATS the appearance of her lungs was grossly abnormal and a biopsy was sent for histological analysis. After a HRCT and specialist staining of her lung biopsy the diagnosis of lymphangioleiomyomatosis was established.
We assessed the use of videoconferencing as an educational tool for students and emergency nurse practitioners based at a minor injuries unit. Nineteen teaching sessions were conducted by videoconferencing, followed by a debriefing session in which the participants made observations about their educational experience. The participants observed that the experience was rewarding. The success of the teaching session depended on group size: an upper limit of six is recommended. The teaching sessions encouraged debate, independent thinking and peer communication.
Numerous studies of putative biomarkers in patients with acute lung injury (ALI) have been conducted to date, but none has proved worthy of entering routine clinical practice, largely because they have shown no clear advantage over clinical predictors (1, 2). Furthermore, the exemplar biomarker for ALI would be biologically plausible, sensitive, and highly specific, adding prognostic information independent of existing systems. The marker should also vary in proportion to the severity of injury and reflect the effects of therapeutic intervention. Conceivably, it would identify subgroups of patients who would benefit from specific therapies targeted at relevant pathogenetic pathways. Ideally, it would be inexpensive and rapidly quantified in a highly reproducible fashion. In this context, a prospective study published in this issue of Critical Care Medicine by Jabaudon et al (3) investigates whether the soluble form of the receptor for advanced glycation end products (sRAGE), is a valuable biomarker in patients with ALI regardless of whether it was associated with severe sepsis or septic shock.
We congratulate Curtis on his excellent review on the very important and under-recognised topic of palliation in end-stage chronic obstructive pulmonary disease (COPD). We agree that the use of noninvasive ventilation (NIV) as palliation may be impractical in the hospice environment, and that NIV should not be used first-line for the palliation of breathlessness in COPD. However, we do not think that there is sufficient recognition that in certain specific circumstances NIV may have a role in end-stage COPD.
The benefits of noninvasive ventilation (NIV) for acute hypercapnic respiratory failure caused by chronic obstructive pulmonary disease (COPD) are well recognized and consequently its use is widespread. Prognostication in advanced COPD is imperfect, limiting accurate identification of 'end-stage' COPD. Decisions regarding withholding invasive ventilation are largely dependent upon prognostication. In patients where 'invasive' ventilation is not considered to be in their best interests, NIV will be the ceiling of therapy. In this patient group, NIV is extremely valuable in reducing mortality and providing valuable symptomatic benefit. We discuss the use of NIV in the management of an acute exacerbation of 'end-stage' COPD where NIV is the ceiling of therapy, the use of advanced directives and the implications of the Mental Capacity Act 2005 on decisions regarding end-of-life care. We highlight areas where further research would be useful. © SAGE Publications 2008.
Pathansali R., Mangoni A.A., Creagh-Brown Ben, Lan Z.-C., Ngow G.-L., Yuan X.-F., Ouldred E.L., Sherwood R.A., Swift C.G., Jackson S.H.D. (2006) Effects of folic acid supplementation on psychomotor performance and hemorheology in healthy elderly subjects,Archives of Gerontology and Geriatrics43(1)pp. 127-137 Elsevier
Cognitive impairment is associated with increased blood concentrations of homocysteine and high blood viscosity. Previous studies have shown that vitamin B supplementation reduces homocysteine and enhances cognitive function in patients with mild dementia and low serum folic acid. However, whether folic acid enhances cognitive function in elderly subjects without dementia and normal serum folic acid is unknown. Twenty-four healthy elderly subjects (age 73.0+/-5.6 years, mean+/-S.D.) with normal serum folic acid (6.3+/-2.4 microg/l) and Mini Mental State Examination (MMSE) >27/30 were randomized to 4-week treatment with folic acid 5mg/day or placebo in a randomized, placebo-controlled, parallel-group study. Continuous Attention Test (CAT), Four-Choice Reaction Time (FCRT), Digit-Symbol Substitution (DSS), Scanning Memory Sets (SMS), and blood viscosity for different shear rates were measured before and after treatment. Folic acid supplementation induced a significant increase in serum folic acid levels (+13.8 versus +1.6 microg/l, p<0.001) and fall in homocysteine levels (-1.91 versus -0.41 micromol/l, p=0.05) compared to placebo. However, there was no significant change in CAT, FCRT, DSS, SMS, and blood viscosity between the two groups. Short-term folic acid supplementation does not enhance psychomotor performance or reduce blood viscosity in healthy elderly subjects with normal serum folic acid levels and preserved cognitive function.
Background: The sepsis syndromes, frequently complicated by pulmonary and cardiac dysfunction, remain a major cause of death amongst the critically ill. Targeted therapies aimed at ameliorating the systemic inflammation that characterises the sepsis syndromes have largely yielded disappointing results in clinical trials. Whilst there are many potential reasons for lack of success of clinical trials, one possibility is that the pathways targeted, to date, are only modifiable very early in the course of the illness. More recent approaches have therefore attempted to identify pathways that could offer a wider therapeutic window, such as the receptor for advanced glycation end-products (RAGE) and its ligands.
Purpose: The objectives of this study were to review the evidence supporting the role of the RAGE axis in systemic inflammation and associated acute lung injury and myocardial dysfunction, to explore some of the problems and conflicts that these RAGE studies have raised and to consider strategies by which they might be resolved.
Methods: MEDLINE was searched (1990-2010) and relevant literature collected and reviewed.
Results and conclusion: RAGE is an inflammation-perpetuating receptor with a diverse range of ligands. Evidence supporting a role of the RAGE axis in the pathogenesis of systemic inflammation, ALI and myocardial dysfunction is compelling with numerous animal experiments showing the beneficial effects of inhibiting the RAGE axis. Despite a number of unanswered questions that need to be further addressed, the potential for inhibiting RAGE-mediated inflammation in humans undoubtedly exists.
Background. The receptor for advanced glycation end products (RAGE) is an inflammation-perpetuating receptor, and soluble RAGE (sRAGE) is a marker of cellular RAGE expression. This study investigated whether raised plasma levels prior to surgery of sRAGE or S100A8/A9 (a RAGE ligand) were associated with longer duration of hospital care in patients undergoing cardiac surgery necessitating cardiopulmonary bypass.
Methods. Patients (n=130) undergoing elective cardiac surgery were enrolled prospectively. Plasma sRAGE and S100A8/A9 concentrations were measured before and 2 h after surgery.
Results. Preoperative plasma sRAGE increased significantly (PÂ0.0001) from 1.06 ng/mL (IQR, 0.72-1.76) to 1.93 ng/mL (IQR, 1.14-2.63) 2 h postoperatively. Plasma S100A8/9 was also significantly (PÂ0.0001) higher 2 h postoperatively (2.37 g/mL, IQR, 1.81-3.05) compared to pre-operative levels (0.41 g/mL, IQR, 0.2-0.65). Preoperative sRAGE, but not S100A8/A9, was positively and significantly correlated with duration of critical illness (r=0.3, P=0.0007) and length of hospital stay (LOS; r=0.31, PÂ0.0005). Multivariate binary logistic regression showed preoperative sRAGE to be, statistically, an independent predictor of greater than median duration of critical illness (odds ratio 16.6, P=0.014) and to be, statistically, the strongest independent predictor of hospital LOS.
Conclusion. Higher preoperative plasma sRAGE levels were associated with prolonged duration of care in adults undergoing cardiac surgery requiring cardiopulmonary bypass.
SIR?The Tempa.Dot single-use thermometer has been in
use in the UK for over 10 years and in the USA for nearly
30 years. Over the last 7 years it has been marketed by 3M
Health Care Limited. Its use in the NHS followed the
European Union Directive to reduce the medical use of
mercury. It also has the advantages of lack of cross-infection
risk and more rapid recordings. A sensor matrix at the tip of
the thermometer consists of 50 temperature-indicating dots,
each with a melting point separation of 0.1 °C. At any given
temperature within the range 35.5?40.4 °C, all dots with a melting point at or below that temperature change colour
from beige to bright blue. Temperature readings are indicated by the number on the thermometer that corresponds
with the row of the last blue dot plus 0.1 °C for every blue
dot in that row greater than one. Tempa.Dot
complies with European published standard EN-12470-
02(P2). This requires the mean accuracy to be within 0.1 °C
for each dot
Nitric oxide (NO) is an endogenous mediator of vascular tone and host defence. Inhaled nitric oxide (iNO) results in preferential pulmonary vasodilatation and lowers pulmonary vascular resistance. The route of administration delivers NO selectively to ventilated lung units so that its effect augments that of hypoxic pulmonary vasoconstriction and improves oxygenation. This 'Bench-to-bedside' review focuses on the mechanisms of action of iNO and its clinical applications, with emphasis on acute lung injury and the acute respiratory distress syndrome. Developments in our understanding of the cellular and molecular actions of NO may help to explain the hitherto disappointing results of randomised controlled trials of iNO.
Campbell and Bah-Sow describe
the varied patterns of abnormality in chest
radiographs in patients with pulmonary
tuberculosis, appearances often being less
specific in immunocompromised patients.1
We agree that a high index of suspicion is
necessary in such patients
and highlight the inadequacy of a chest radiograph
in excluding pulmonary
tuberculosis.
Nitric oxide (NO) is a naturally-occurring free radical that exists as a colorless and odorless gas. In biological solutions, NO is highly diffusible both in water and through biological membranes, with a half-life measured in seconds. Prior to the recognition that NO was the same molecule as an endothelium-derived relaxing factor some 20 years ago it was considered to be mainly an environmental pollutant. However, NO is now recognized as an endogenously produced vasodilator that modulates vascular tone and, thereby, regulates systemic and pulmonary blood flow. It has also been found to have diverse roles throughout mammalian physiology, including neurotransmission and host defense.
A 39-year-old man presented to the emergency department (ED) in severe respiratory distress. He had a prior diagnosis of brittle asthma and had been admitted on several occasions but never previously ventilated. Therapy given in the first 3 hours of arrival included nebulized salbutamol (5 mg, ×5), ipratropium bromide (0.5 mg), intravenous hydrocortisone (200 mg), and magnesium sulfate (2 g). His arterial blood gases continued to deteriorate. He was then given an intravenous bolus of salbutamol (250 ¼g) and heliox via facemask. His worsening status necessitated invasive ventilation. His hypercapnia and resultant respiratory acidosis improved rapidly, but there was a concurrent accumulation of lactic acid resulting in acidemia. This patient had lactic acidosis as a direct effect of administration of salbutamol. The development of hazardous salbutamol-induced toxicity in acute severe asthma is discussed.
Experience in critical care medicine is mandatory for all respiratory trainees in the UK with a need for 60 days (3 months) minimum placement in an intensive care unit (ICU). The Respiratory Critical Care Group of the British Thoracic Society1 recently reported a survey in which there was widespread agreement with this requirement, although it was inadequately provided by a number of programmes. In addition, a proportion of trainees indicated the intention to subspecialise in intensive care medicine and were concerned that their ICU experience was diluted by having responsibilities such as acute general medical takes during their attachment. We recently carried out an email survey of anaesthetic and respiratory trainees and directors of intensive care which provides additional useful information.
Objective: We describe the emergency use of a covered, expandable, removable tracheal stent in a patient who developed a large posterior tracheal tear complicating endobronchial therapy for large airway obstruction. Method: Case report and review of the literature concerning management of acute tracheal tear. Results and conclusion: Our patient demonstrates that endotracheal stenting is an option for managing acute large airway tear. Moreover, the use of a removable stent allows not only for rapid closure of the defect but also removal once the defect has healed, thus avoiding long-term complications of stent deployment.
Management of the profoundly anaemic patient who competently refuses blood transfusion will always prove challenging. This article provides a review of treatment strategies based around a recent case of a patient presenting after major gastrointestinal haemorrhage. The main part of management involves providing supportive intensive care, paying particular attention to oxygen delivery and consumption, and minimising further blood loss. Specific treatments, such as pharmacotherapy to promote erythropoiesis, are based largely on indirect evidence or expert opinion. Virtually all aspects of care involve carefully balancing a shifting profile of risks and benefits; a team approach and close communication with the family are essential. This patient's successful outcome has extended our understanding of this area, which is discussed. © The Intensive Care Society 2014.
Background
Forty per cent of critically ill patients are affected by intensive care unit-acquired weakness (ICU-AW), to which skeletal muscle wasting makes a substantial contribution. This can impair outcomes in hospital, and can cause long-term physical disability after hospital discharge. No effective mitigating strategies have yet been identified.
Application of a repetitive vascular occlusion stimulus (RVOS) a limb pressure cuff inducing brief repeated cycles of ischaemia and reperfusion, can limit disuse muscle atrophy in both healthy controls and bed-bound patients recovering from knee surgery. We wish to determine whether RVOS might be effective in mitigating against muscle wasting in the ICU. Given that RVOS can also improve vascular function in healthy controls, we also wish to assess such effects in the critically ill. We here describe a pilot study to assess whether RVOS application is safe, tolerable, feasible and acceptable for ICU patients.
Methods
This is a randomised interventional feasibility trial. Thirty-two ventilated adult ICU patients with multiorgan failure will be recruited within 48 h of admission and randomised to either the intervention arm or the control arm. Intervention participants will receive RVOS twice daily (except only once on day 1) for up to 10 days or until ICU discharge.
Serious adverse events and tolerability (pain score) will be recorded; feasibility of trial procedures will be assessed against pre-specified criteria and acceptability by semi-structured interview. Together with vascular function, muscle mass and quality will be assessed using ultrasound and measures of physical function at baseline, on days 6 and 11 of study enrolment, and at ICU and hospital discharge. Blood and urine biomarkers of muscle metabolism, vascular function, inflammation and DNA damage/repair mechanism will also be analysed. The Health questionnaire will be completed 3 months after hospital discharge.
Discussion
If this study demonstrates feasibility, the derived data will be used to inform the design (and sample size) of an appropriately-powered prospective trial to clarify whether RVOS can help preserve muscle mass/improve vascular function in critically ill patients.
Background:
Sepsis is life-threatening organ dysfunction because of a dysregulated host response to infection. Disturbed microvascular blood flow is associated with excess mortality and is a potential future target for interventions. This review addresses the evidence for pharmacological manipulation of the microcirculation in sepsis assessed by techniques that evaluate the sublingual microvasculature.
Methods:
Systematic review using a published protocol. Eligibility criteria were studies of septic patients published from January 2000 to February 2018. Interventions were drugs aimed at improving perfusion. Outcome was improvement in microvascular flow using orthogonal polarization spectral, sidestream dark field, or incident dark field imaging (Grades of Recommendation, Assessment, Development, and Evaluation criteria used).
Results:
Two thousand six hundred and six articles were screened and 22 included. (6 randomized controlled trials, 12 interventional, 3 observational, and 1 pilot, n = 572 participants). Multiple measurement techniques were described, including: automated analyses, subjective, and composite scoring systems. Norepinephrine was not found to improve microvascular flow (low-grade evidence, n = 6 studies); except in chronic hypertension (low, n = 1 study). Addition of arginine vasopressin or terlipressin to norepinephrine maintained flow while decreasing norepinephrine requirements (high, n = 2 studies). Neither dobutamine nor glyceryl trinitrate consistently improved flow (low, n = 6 studies). A single study (n = 40 participants) demonstrated improved flow with levosimendan (high). In a risk of bias assessment 16/16 interventional, pilot and observational studies were found to be high risk.
Conclusions:
There is no robust evidence to date that any one agent can reproducibly lead to improved microvascular flow. Furthermore, no study demonstrated outcome benefit of one therapeutic agent over another. Updated consensus guidelines could improve comparable reporting of measurements and reduce bias, to enable meaningful comparisons around the effects of individual pharmacological agents.
