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Volume 14 Number 1 January 2013
Editorial
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This month in JICS
By Neil Soni
2013 will be a great year for British intensive care. All the elements key to the definition of a specialty are now in place. They will provide a firm foundation for the now burgeoning specialty rapidly acquiring a pivotal role in hospital practice with the status that accompanies that position. In the broader sense the consolidation of the specialty will enable the development of British intensive care as a brand amalgamating the international recognition already enjoyed by the many impressive British contributors on the world stage
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Confirming death using neurological criteria: are two sets of tests better than one? 2CO6 3C00
By Dale Gardiner, Chris Danbury, Alex Manara
The Academy of Medical Royal Colleges published the latest guidance on the diagnosis and confirmation of death in 2008.1 It supersedes the previous versions and updates of the Code of Practice published in 1976,2 1979,3 19834 and 19985 and is notable for being the first to provide guidance on the diagnosis of death using circulatory-respiratory criteria as well as that using neurological criteria.
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Original articles
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Leucocytosis following transfusion with leucodepleted red cells to non-bleeding critically ill patients 3C00
By Ezzeldin Saleh,ÊTimothy S Walsh
Previous studies have shown that transfusion of non-leucodepleted red blood cells can cause leucocytosis in recipients. A small study suggested that pre-storage leucodepletion removed this phenomenon, but has not been further substantiated. We explored whether recipient leucocytosis occurs when leucodepleted red blood cells were transfused to non-bleeding intensive care patients. We used routinely collected data for 95 transfusions in 54 patients. Overall, no leucocytosis was found on the first routine blood sample following transfusion (mean change 0.6 x 109/L; 95% confidence interval Ð?0.2 to 1.3; p=0.145). However, for the 32 transfusions in patients with normal pre-transfusion leucocyte count there was a clinically small but statistically significant leucocytosis following transfusion, unlikely to have occurred by chance (mean change 1.5 x 109/L; 0.5 to 2.5; p=0.005). No significant change was observed in patients with pre-transfusion leucocytosis. We found no relation between leucocytosis and storage age of red cells. Our data suggest that transfusions with leucodepleted red cells can increase leucocyte counts in recipients. The mechanism of this effect and its clinical importance are uncertain.
Keywords: leucocytosis; blood transfusion; critical illness
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The introduction of intensive care-led echocardiography into a tertiary care unit 2C01, 3C00
By Shirjel Alam,ÊAnnemarie Docherty,ÊIan Mackle,ÊMichael Gillies
The objective of this study was to evaluate the feasibility and impact of an intensive care-led trans-thoracic echocardiography (TTE) service replacing a cardiology-led service. Three intensivists were trained and accredited with the British Society of Echocardiography, and between 1st February and 1st August 2010 intensive care implemented a 24-hour scanning service. A prospective observational study was performed to examine the impact in our tertiary referral general intensive care unit. ECG, echocardiographic findings, technical difficulties and any changes in management made as a result of a TTE were recorded. Of 125 attempted scans, 120 patients had full studies (96%), four had limited studies (3%) and one was not possible. TTE changed management in 61 (49%) cases. This compares to only 57 scans performed in total in the preceding six months with a cardiology-led service. We conclude that intensive care-led TTE is feasible when carried out by trained staff, led to greater use of echocardiography and a change in management in almost half the patients studied.
Keywords: intensive care; echocardiography; haemodynamic monitoring; cardiac output; cardiac function; ECG
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Ethics
Review article
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Should benzodiazepine sedation be delivered by infusion or bolus? 1A02, 2C05
By James Hutchinson,ÊGeorgina Harlow,ÊDavid Sinton,ÊTony Whitehouse
Benzodiazepine sedation for mechanically ventilated patients in intensive care (ICU) is common practice worldwide. We performed a literature review to investigate whether benzodiazepine sedation is best delivered by continuous infusion or intermittent bolus. PubMed, Ovid and Cochrane databases were searched. Only four studies, involving 481 patients, were found. Three were randomised controlled trials and one was an observational cohort study; all used different benzodiazepines, sometimes in conjunction with opiates. The studies measured different outcomes including mechanical ventilation duration, length of ICU and hospital stay, quality and complications of sedation and mortality. Use of intermittent sedation or opiate boluses alone reduced mechanical ventilation duration, ICU and hospital length of stay. However such limited data means that the optimal mode of delivery for benzodiazepine sedation remains unresolved.
Keywords: sedation; benzodiazepine; infusion; bolus; mechanical ventilation
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Intensive care management of subarachnoid haemorrhage 2C04, 3C00
By David Highton,ÊMartin Smith
Aneurysmal subarachnoid haemorrhage (SAH) is a devastating disease associated with high mortality and poor outcome in many survivors. Aggressive treatment by a comprehensive multidisciplinary team is associated with improved outcome, but the intensive care management of SAH presents significant challenges. Multimodal neuromonitoring may detect secondary insults before irreversible neuronal damage has occurred, and is increasingly being used to guide treatment. This article reviews current trends in the intensive care management of SAH from aspects of initial resuscitation to recent developments in the prevention and management of complications, including delayed cerebral ischaemia. Evidence from clinical trials and recent consensus guidance is reviewed.
Keywords: subarachnoid haemorrhage; delayed cerebral ischaemia; cerebral vasospasm; multimodal monitoring
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Pulmonary embolism in the mechanically-ventilated critically ill patient: is it different? 2C03, 3C00
By Vasileios A Zochios,ÊAlex Keeshan
Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
Keywords: critical illness; mechanical ventilation; pulmonary embolism; echocardiography; venous thromboembolism
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Human albumin solution resuscitation in severe sepsis and septic shock 1A02, 2C04, 3C00
By Andrew Leitch,ÊGordon Craig,ÊPaul Sadler
There has been a recent resurgence of interest in the use of human albumin solution (HAS) for the resuscitation of critically ill patients. In particular, it may be beneficial for patients with severe sepsis and septic shock. We outline the evidence for the biological plausibility of this effect, perform a meta-analysis of randomised controlled trials comparing the effect of HAS with other fluid resuscitation on mortality in this group of patients and discuss the likely contribution of recently completed trials in this area. We included nine trials of 1,435 patients in the meta-analysis. Although HAS resuscitation was associated with a trend to lower mortality (relative risk 0.90, 95% confidence interval 0.79-1.02), we found that most trials reported to date are small and of variable methodological quality. The questions of a potential differential effect of dose on outcome and the pharmacological variability of HAS products have not been adequately addressed to date. We conclude that the routine administration of HAS to patients with severe sepsis and septic shock is difficult to justify on the basis of current knowledge.
Keywords: plasma substitutes; albumins; sepsis; resuscitation; meta-analysis
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Delirium uncovered 2C01, 3C00
By Timothy M Alce,ÊValerie Page,ÊMarcela P Vizcaychipi
Delirium is defined as an acute confusional state with a disturbance of consciousness and a change in cognition which is fluctuating and self-limited in the vast majority of the cases. It is common in intensive care, most frequently in its hypoactive manifestation, and is associated with increased morbidity and mortality. This article reviews the pathogenesis, risk factors, diagnostic assessment, prevention and management of delirium.
Keywords: delirium; intensive care; CAM-ICU; confusional syndrome; brain dysfunction
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Audits and surveys
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A survey of the implementation of the NHS diabetes guidelines for management of diabetic ketoacidosis in the intensive care units of the East of England 3C00
By Bryony Rudd,ÊKrishna Patel,ÊNicholas Levy,ÊKetan Dhatariya
For patients with insulin-treated diabetes, diabetic ketoacidosis (DKA) is a serious acute complication that often leads to intensive care admission. To overcome perceived shortcomings in care, the Joint British Diabetes Societies (JBDS) published national guidelines for the management of DKA in adults in March 2010. A telephone survey of the 13 general adult intensive care units in the East of England during November 2011 examined how widely four key steps of the guidelines had been adopted in the region. The survey demonstrated that while most units had guidelines for the management of DKA, the majority had not adopted the JBDS guidelines. We recommend that future national guidelines for DKA are developed with the participation of the intensive care community and are disseminated to all intensivists.
Keywords: diabetes; diabetic ketoacidosis; guidelines
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Case reports
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A case of refractory seizures caused by an unusual zoonosis 3C00
By James Walkington,ÊMruthunjaya Hulgur,ÊDavid Yates
A 29-year-old female presented to the intensive care unit with refractory status epilepticus. Despite treatment with anticonvulsants and sedation, she continued to have EEG evidence of seizure activity that terminated only with volatile anaesthetic agents. There was serological evidence of exposure to a flavivirus. In the UK the only endemic flavivirus is Louping ill, which is closely related to tick-borne encephalitis. It was likely that this was the cause. She remained on intensive care for almost six months and failed to regain consciousness.
Keywords: zoonosis; refractory status epilepticus; louping ill; tick-borne encephalitis; volatile anaesthetic
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State of the Art abstracts
CAT reviews
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Efficacy and safety of regional citrate anticoagulation in critically ill patients undergoing continuous renal replacement therapy 1A02, 3C00
By James Sheehan,ÊMartyn Ezra
A meta-analysis of randomised controlled trials comparing regional citrate anticoagulation (RCA) to control anticoagulation for haemofiltration revealed that citrate anticoagulation is effective at maintaining circuit patency and reducing the risk of bleeding during haemofiltration. The use of regional citrate anticoagulation also prolongs the haemofiltration circuit life, but this result is not significant when compared to the use of heparin. There was however, marked heterogeneity between trials reported. Level of evidence: 1- (Meta-analysis with a high risk of bias)
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Comment
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Inadverdent obstruction of the pilot balloon of a tracheostomy tube
By Kandasamy Krishnan,ÊRenjith Joseph
We report a recent incident in our intensive care unit. A patient was on pressure-controlled ventilation through a tracheostomy due to an acute lung injury. There was a leak and bubbling noise through the mouth during ventilation. Initially, we thought it might be due to a cuff leak but the cuff pressure was checked and was normal. The contour of the pilot balloon was not altered; however, it was not possible to achieve adequate ventilation due to the leak. We decided to change the tracheostomy tube.
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ICU airway management
By Prashant Parulekar,ÊRichard Venn,ÊPatrick Carr
The fourth National Audit Project (NAP4) of the Royal College of Anaesthetists identified 36 cases of major complications of airway management in the intensive care unit (ICU) over a 12-month period.1 NAP4 recommended that Ôtrainee medical staff should be proficient in emergency airway management.Õ2
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A case of pink urine discolouration following amitriptyline overdose
By Pavan K Battu,ÊTim Wenham
Certain foods, drugs and infections can cause discoloured urine. Pink discolouration of urine, although uncommon, has been reported in obese patients sedated with propofol postoperatively. We present a case of pink discolouration of urine in an obese patient admitted to the intensive care unit (ICU) following an amitryptiline overdose and discuss the importance of considering alternative sedation agents.
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PopeyeÕs sign
By Nigel Tufft
I should like to name a physical sign after the cartoon hero Popeye who is easily identifiable by his pipe and his bulging forearms. This sign has arisen as a result of the change in intensive care practice over the last decade or so.
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Report
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Lemmingaid: If
By Wood and Trees
The imagination is a wonderful part of the human condition. In childhood, the world is as full of possibilities as the imagination allows, which is, of course, infinite. Little girls can be princesses, little boys, valiant knights. Beans turn into beanstalks, rainbows have pots of gold and the genie will grant your every wish. Cats and dogs do understand what you say, there is a sweet shop where all the best sweets are free and you never have to eat broccoli again.
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E-supplement research poster presentations
| Articles considered suitable for CPD have appropriate codes from the CPD matrix for Intensive Care Medicine, as approved by the Faculty of Intensive Care Medicine. |
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