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Jiwaji Z, Brady S, McIntyre LA, Gray A, Walsh TS. Emergency department management of early sepsis: a national survey of emergency medicine and intensive care consultants. Emerg Med J 2014; 31:1000-5. [PMID: 24005642 DOI: 10.1136/emermed-2013-202883] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Early goal-directed therapy (EGDT) is recommended for sepsis management in current guidelines, but the underpinning evidence is controversial. Clinician beliefs and the capacity to implement all recommended elements of EGDT in emergency departments (EDs) are uncertain. Our study aimed to explore self-reported management of early sepsis by Scottish emergency medicine (EM) and intensive care medicine (ICM) consultants, delineate important differences and determine the guideline recommendations rated most important and deliverable within the ED. METHODS A postal survey using a hypothetical patient with septic shock was sent to all EM and ICM consultants practising in Scotland. RESULTS 67% (76/114) EM and 61% (96/157) ICM consultants responded. Normal saline was preferred by EM respondents ('always/often used': EM 86%, ICM 23%, p<0.0001), whereas ICM respondents preferred Hartmann's solution (EM 42%, ICM 72%, p=0.0164), gelofusin (EM 10%, ICM 63%, p<0.0001) and starch (EM 0%, ICM 24%, p<0.0001). More ICM respondents indicated they used central venous pressure and invasive arterial pressure monitoring in the ED, and initiated vasopressors (EM 57%, ICM 90%, p<0.0001). More ICM consultants used specific haemoglobin transfusion triggers (48% EM, 77% ICM, p=0.0002), but marked variation in haemoglobin triggers and targets was reported. Lactate was rated the most important single resuscitation parameter by both specialties; no ED and only two ICM consultants rated ScVO2 most important. CONCLUSIONS Differences in early fluid and vasopressor management of sepsis exist between Scottish ICM and EM consultants. Transfusion practice is highly variable, suggesting clinical uncertainty. Lactate is considered more important than ScVO2 measurement.
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Hellyer TP, Morris AC, McAuley DF, Walsh TS, Anderson NH, Singh S, Dark P, Roy AI, Baudouin SV, Wright SE, Perkins GD, Kefala K, Jeffels M, McMullan R, O'Kane CM, Spencer C, Laha S, Robin N, Gossain S, Gould K, Ruchaud-Sparagano MH, Scott J, Browne EM, MacFarlane JG, Wiscombe S, Widdrington JD, Dimmick I, Laurenson IF, Nauwelaers F, Simpson AJ. Diagnostic accuracy of pulmonary host inflammatory mediators in the exclusion of ventilator-acquired pneumonia. Thorax 2014; 70:41-7. [PMID: 25298325 PMCID: PMC4992819 DOI: 10.1136/thoraxjnl-2014-205766] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Excessive use of empirical antibiotics is common in critically ill patients. Rapid biomarker-based exclusion of infection may improve antibiotic stewardship in ventilator-acquired pneumonia (VAP). However, successful validation of the usefulness of potential markers in this setting is exceptionally rare. OBJECTIVES We sought to validate the capacity for specific host inflammatory mediators to exclude pneumonia in patients with suspected VAP. METHODS A prospective, multicentre, validation study of patients with suspected VAP was conducted in 12 intensive care units. VAP was confirmed following bronchoscopy by culture of a potential pathogen in bronchoalveolar lavage fluid (BALF) at >10(4) colony forming units per millilitre (cfu/mL). Interleukin-1 beta (IL-1β), IL-8, matrix metalloproteinase-8 (MMP-8), MMP-9 and human neutrophil elastase (HNE) were quantified in BALF. Diagnostic utility was determined for biomarkers individually and in combination. RESULTS Paired BALF culture and biomarker results were available for 150 patients. 53 patients (35%) had VAP and 97 (65%) patients formed the non-VAP group. All biomarkers were significantly higher in the VAP group (p<0.001). The area under the receiver operator characteristic curve for IL-1β was 0.81; IL-8, 0.74; MMP-8, 0.76; MMP-9, 0.79 and HNE, 0.78. A combination of IL-1β and IL-8, at the optimal cut-point, excluded VAP with a sensitivity of 100%, a specificity of 44.3% and a post-test probability of 0% (95% CI 0% to 9.2%). CONCLUSIONS Low BALF IL-1β in combination with IL-8 confidently excludes VAP and could form a rapid biomarker-based rule-out test, with the potential to improve antibiotic stewardship.
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Jiwaji Z, Nunn KP, Conway-Morris A, Simpson AJ, Wyncoll D, Rossi AG, Walsh TS. Leukoreduced blood transfusion does not increase circulating soluble markers of inflammation: a randomized controlled trial. Transfusion 2014; 54:2404-11. [DOI: 10.1111/trf.12669] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Revised: 02/03/2014] [Accepted: 02/23/2014] [Indexed: 02/01/2023]
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Barr LC, Brittan M, Morris AC, McAuley DF, McCormack C, Fletcher AM, Richardson H, Connell M, Patel D, Wallace WAH, Rossi AG, Davidson DJ, Manson L, Turner M, Hirani N, Walsh TS, Anderson NH, Dhaliwal K, Simpson AJ. Reply: The Alveolar Macrophage and Acute Respiratory Distress Syndrome: A Silent Actor? Am J Respir Crit Care Med 2014; 189:500-1. [DOI: 10.1164/rccm.201309-1725le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Conway Morris A, Wilkinson TS, Walsh TS, Simpson AJ. Comment on "changes and regulation of the C5a receptor on neutrophils during septic shock in humans". THE JOURNAL OF IMMUNOLOGY 2013; 191:4893. [PMID: 24185822 DOI: 10.4049/jimmunol.1390060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Walsh TS, Morris AC, Simpson AJ. Ventilator associated pneumonia: can we ensure that a quality indicator does not become a game of chance? Br J Anaesth 2013; 111:333-7. [PMID: 23946358 DOI: 10.1093/bja/aet131] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Barr LC, Brittan M, Morris AC, McAuley DF, McCormack C, Fletcher AM, Richardson H, Connell M, Patel D, Wallace WAH, Rossi AG, Davidson DJ, Manson L, Turner M, Hirani N, Walsh TS, Anderson NH, Dhaliwal K, Simpson AJ. A randomized controlled trial of peripheral blood mononuclear cell depletion in experimental human lung inflammation. Am J Respir Crit Care Med 2013; 188:449-55. [PMID: 23627345 DOI: 10.1164/rccm.201212-2334oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Depletion of monocytes reduces LPS-induced lung inflammation in mice, suggesting monocytes as potential therapeutic targets in acute lung injury. OBJECTIVES To investigate whether depletion of circulating blood monocytes has beneficial effects on markers of systemic and pulmonary inflammation in a human model of acute lung inflammation. METHODS A total of 30 healthy volunteers were enrolled in a randomized controlled trial. Volunteers inhaled LPS at baseline, and were randomized to receive active mononuclear cell depletion by leukapheresis, or sham leukapheresis, in a double-blind fashion (15 volunteers per group). Serial blood counts were measured, bronchoalveolar lavage (BAL) was performed at 9 hours, and [(18)F]fluorodeoxyglucose positron emission tomography at 24 hours. The primary endpoint was the increment in circulating neutrophils at 8 hours. MEASUREMENTS AND MAIN RESULTS As expected, inhalation of LPS induced neutrophilia and an up-regulation of inflammatory mediators in the blood and lungs of all volunteers. There was no significant difference between the depletion and sham groups in the mean increment in blood neutrophil count at 8 hours (6.16 × 10(9)/L and 6.15 × 10(9)/L, respectively; P = 1.00). Furthermore, there were no significant differences in BAL neutrophils or protein, positron emission tomography-derived measures of global lung inflammation, or cytokine levels in plasma or BAL supernatant between the study groups. No serious adverse events occurred, and no symptoms were significantly different between the groups. CONCLUSIONS These findings do not support a role for circulating human monocytes in the early recruitment of neutrophils during LPS-mediated acute lung inflammation in humans.
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Conway Morris A, Anderson N, Brittan M, Wilkinson TS, McAuley DF, Antonelli J, McCulloch C, Barr LC, Dhaliwal K, Jones RO, Haslett C, Hay AW, Swann DG, Laurenson IF, Davidson DJ, Rossi AG, Walsh TS, Simpson AJ. Combined dysfunctions of immune cells predict nosocomial infection in critically ill patients. Br J Anaesth 2013; 111:778-87. [PMID: 23756248 DOI: 10.1093/bja/aet205] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Nosocomial infection occurs commonly in intensive care units (ICUs). Although critical illness is associated with immune activation, the prevalence of nosocomial infections suggests concomitant immune suppression. This study examined the temporal occurrence of immune dysfunction across three immune cell types, and their relationship with the development of nosocomial infection. METHODS A prospective observational cohort study was undertaken in a teaching hospital general ICU. Critically ill patients were recruited and underwent serial examination of immune status, namely percentage regulatory T-cells (Tregs), monocyte deactivation (by expression) and neutrophil dysfunction (by CD88 expression). The occurrence of nosocomial infection was determined using pre-defined, objective criteria. RESULTS Ninety-six patients were recruited, of whom 95 had data available for analysis. Relative to healthy controls, percentage Tregs were elevated 6-10 days after admission, while monocyte HLA-DR and neutrophil CD88 showed broader depression across time points measured. Thirty-three patients (35%) developed nosocomial infection, and patients developing nosocomial infection showed significantly greater immune dysfunction by the measures used. Tregs and neutrophil dysfunction remained significantly predictive of infection in a Cox hazards model correcting for time effects and clinical confounders {hazard ratio (HR) 2.4 [95% confidence interval (CI) 1.1-5.4] and 6.9 (95% CI 1.6-30), respectively, P=0.001}. Cumulative immune dysfunction resulted in a progressive risk of infection, rising from no cases in patients with no dysfunction to 75% of patients with dysfunction of all three cell types (P=0.0004). CONCLUSIONS Dysfunctions of T-cells, monocytes, and neutrophils predict acquisition of nosocomial infection, and combine additively to stratify risk of nosocomial infection in the critically ill.
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Wilkinson TS, Conway Morris A, Kefala K, O'Kane CM, Moore NR, Booth NA, McAuley DF, Dhaliwal K, Walsh TS, Haslett C, Sallenave JM, Simpson AJ. Ventilator-associated pneumonia is characterized by excessive release of neutrophil proteases in the lung. Chest 2013; 142:1425-1432. [PMID: 22911225 DOI: 10.1378/chest.11-3273] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is characterized by neutrophils infiltrating the alveolar space. VAP is associated with high mortality, and accurate diagnosis remains difficult. We hypothesized that proteolytic enzymes from neutrophils would be significantly increased and locally produced inhibitors of human neutrophil elastase (HNE) would be decreased in BAL fluid (BALF) from patients with confirmed VAP. We postulated that in suspected VAP, neutrophil proteases in BALF may help identify "true" VAP. METHODS BAL was performed in 55 patients with suspected VAP and in 18 control subjects. Isolation of a pathogen(s) at > 10⁴ colony-forming units/mL of BALF dichotomized patients into VAP (n = 12) and non-VAP (n = 43) groups. Matrix metalloproteinases (MMPs), HNE, inhibitors of HNE, and tissue inhibitors of matrix metalloproteinases (TIMPs) were quantified. Plasminogen activator (PA) activity was estimated by sodium dodecyl sulfate polyacrylamide gel electrophoresis and zymography. RESULTS Neutrophil-derived proteases HNE, MMP-8, and MMP-9 were significantly increased in cell-free BALF from patients with VAP as compared with those without VAP (median values: HNE, 2,708 ng/mL vs 294 ng/mL, P < .01; MMP-8, 184 ng/mL vs 5 ng/mL, P < .01; MMP-9, 310 ng/mL vs 11 ng/mL, P < .01). HNE activity was also significantly increased in VAP (0.45 vs 0.01 arbitrary units; P < .05). In contrast, no significant differences were observed for protease inhibitors, TIMPs, or PAs. HNE in BALF, at a cutoff of 670 ng/mL, identified VAP with a sensitivity of 93% and specificity of 79%. CONCLUSIONS Neutrophil proteases are significantly elevated in the alveolar space in VAP and may contribute to pathogenesis. Neutrophil proteases appear to have potential in suspected VAP for distinguishing true cases from "non-VAP" cases.
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Saleh E, Walsh TS. Leucocytosis following Transfusion with Leucodepleted Red Cells to Non-Bleeding Critically Ill Patients. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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 × 109/L; 95% confidence interval - 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 × 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.
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Lone NI, Walsh TS. Impact of Intensive Care Unit Organ Failures on Mortality during the Five Years after a Critical Illness. Am J Respir Crit Care Med 2012; 186:640-7. [DOI: 10.1164/rccm.201201-0059oc] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll DL. Thrombocytopenia and platelet transfusion in UK critical care: a multicenter observational study. Transfusion 2012; 53:1050-8. [DOI: 10.1111/j.1537-2995.2012.03866.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Walsh TS, Palmer J, Watson D, Biggin K, Seretny M, Davidson H, Harkness M, Hay A. Multicentre cohort study of red blood cell use for revision hip arthroplasty and factors associated with greater risk of allogeneic blood transfusion. Br J Anaesth 2012; 108:63-71. [PMID: 22037224 DOI: 10.1093/bja/aer326] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Revision hip arthroplasty (RHA) is associated with high rates of allogeneic blood transfusion (ABT). We aimed to determine factors associated with ABT in patients undergoing RHA in Scottish hospitals, with particular focus on perioperative cell salvage (PCS). METHODS A prospective observational cohort study of RHA procedures performed in 11 hospitals over 7 months was performed. We recorded predefined patient, surgery-related, and blood conservation factors that may influence perioperative ABT, together with postoperative haemoglobin (Hb) data and ABTs to day 7. We explored factors with strongest independent association with ABT during the perioperative period using multiple regression analysis. RESULTS Two hundred and ten cases were studied, of whom 58% received ABTs (mean 1.8 units), most of which (52%) occurred on the day of surgery. Eighty-eight (42%) patients received PCS, of whom 68 had red cells re-infused [mean re-infusion volume 312 ml (1st, 3rd quartile: 260, 363 ml)]. In unadjusted comparisons, patients receiving PCS had lower intraoperative (9% vs 40%) and total (55% vs 63%) exposure to ABTs. The mean (95% confidence interval) theatre blood loss was 1013 (899-1128) ml and was higher for combined femoral/acetabular revision and femoral revision than other categories. The mean postoperative Hb transfusion trigger was 80 g litre(-1). In multivariable models, preoperative Hb [odds ratio (OR) 0.35; P<0.001], patient weight (OR 0.96; P=0.004), operating theatre blood loss (OR 1.002; P<0.001), and re-infusion of PCS blood (OR 0.31; P=0.02) were independent predictors of ABT exposure. CONCLUSIONS PCS is an effective blood conservation strategy for RHA, especially for patients with preoperative anaemia, low body weight, or both.
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Noah MA, Peek GJ, Finney SJ, Griffiths MJ, Harrison DA, Grieve R, Sadique MZ, Sekhon JS, McAuley DF, Firmin RK, Harvey C, Cordingley JJ, Price S, Vuylsteke A, Jenkins DP, Noble DW, Bloomfield R, Walsh TS, Perkins GD, Menon D, Taylor BL, Rowan KM. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306:1659-68. [PMID: 21976615 DOI: 10.1001/jama.2011.1471] [Citation(s) in RCA: 601] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
CONTEXT Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic. OBJECTIVE To compare the hospital mortality of patients with H1N1-related ARDS referred, accepted, and transferred for ECMO with matched patients who were not referred for ECMO. DESIGN, SETTING, AND PATIENTS A cohort study in which ECMO-referred patients were defined as all patients with H1N1-related ARDS who were referred, accepted, and transferred to 1 of the 4 adult ECMO centers in the United Kingdom during the H1N1 pandemic in winter 2009-2010. The ECMO-referred patients and the non-ECMO-referred patients were matched using data from a concurrent, longitudinal cohort study (Swine Flu Triage study) of critically ill patients with suspected or confirmed H1N1. Detailed demographic, physiological, and comorbidity data were used in 3 different matching techniques (individual matching, propensity score matching, and GenMatch matching). MAIN OUTCOME MEASURE Survival to hospital discharge analyzed according to the intention-to-treat principle. RESULTS Of 80 ECMO-referred patients, 69 received ECMO (86.3%) and 22 died (27.5%) prior to discharge from the hospital. From a pool of 1756 patients, there were 59 matched pairs of ECMO-referred patients and non-ECMO-referred patients identified using individual matching, 75 matched pairs identified using propensity score matching, and 75 matched pairs identified using GenMatch matching. The hospital mortality rate was 23.7% for ECMO-referred patients vs 52.5% for non-ECMO-referred patients (relative risk [RR], 0.45 [95% CI, 0.26-0.79]; P = .006) when individual matching was used; 24.0% vs 46.7%, respectively (RR, 0.51 [95% CI, 0.31-0.81]; P = .008) when propensity score matching was used; and 24.0% vs 50.7%, respectively (RR, 0.47 [95% CI, 0.31-0.72]; P = .001) when GenMatch matching was used. The results were robust to sensitivity analyses, including amending the inclusion criteria and restricting the location where the non-ECMO-referred patients were treated. CONCLUSION For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients.
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Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, Brooks O, Laurenson IF, Cook B, Walsh TS. Reducing ventilator-associated pneumonia in intensive care: impact of implementing a care bundle. Crit Care Med 2011; 39:2218-24. [PMID: 21666444 DOI: 10.1097/ccm.0b013e3182227d52] [Citation(s) in RCA: 167] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Ventilator-associated pneumonia is the most common intensive care unit-acquired infection. Although there is widespread consensus that evidenced-based interventions reduce the risk of ventilator-associated pneumonia, controversy has surrounded the importance of implementing them as a "bundle" of care. This study aimed to determine the effects of implementing such a bundle while controlling for potential confounding variables seen in similar studies. DESIGN A before-and-after study conducted within the context of an existing, independent, infection surveillance program. SETTING An 18-bed, mixed medical-surgical teaching hospital intensive care unit. PATIENTS All patients admitted to intensive care for 48 hrs or more during the periods before and after intervention. INTERVENTIONS A four-element ventilator-associated pneumonia prevention bundle, consisting of head-of-bed elevation, oral chlorhexidine gel, sedation holds, and a weaning protocol implemented as part of the Scottish Patient Safety Program using Institute of Health Care Improvement methods. MEASUREMENTS AND MAIN RESULTS Compliance with head-of-bed elevation and chlorhexidine gel were 95%-100%; documented compliance with "wake and wean" elements was 70%, giving overall bundle compliance rates of 70%. Compared to the preintervention period, there was a significant reduction in ventilator-associated pneumonia in the postintervention period (32 cases per 1,000 ventilator days to 12 cases per 1,000 ventilator days; p<.001). Statistical process control charts showed the decrease was most marked after bundle implementation. Patient cohorts staying ≥6 and ≥14 days had greater reduction in ventilator-associated pneumonia acquisition and also had reduced antibiotic use (reduced by 1 and 3 days; p=.008/.007, respectively). Rates of methicillin-resistant Staphylococcus aureus acquisition also decreased (10% to 3.6%; p<.001). CONCLUSIONS Implementation of a ventilator-associated pneumonia prevention bundle was associated with a statistically significant reduction in ventilator-associated pneumonia, which had not been achieved with earlier ad hoc ventilator-associated pneumonia prevention guidelines in our unit. This occurred despite an inability to meet bundle compliance targets of 95% for all elements. Our data support the systematic approach to achieving high rates of process compliance and suggest systematic introduction can decrease both infection incidence and antibiotic use, especially for patients requiring longer duration of ventilation.
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Walsh TS, Lapinlampi TP, Ramsay P, Särkelä MOK, Uutela K, Viertiö-Oja HE. Responsiveness of the frontal EMG for monitoring the sedation state of critically ill patients. Br J Anaesth 2011; 107:710-8. [PMID: 21862496 DOI: 10.1093/bja/aer228] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Excessive sedation is associated with adverse patient outcomes during critical illness, and a validated monitoring technology could improve care. We developed a novel method, the responsiveness index (RI) of the frontal EMG. We compared RI data with Ramsay clinical sedation assessments in general and cardiac intensive care unit (ICU) patients. METHODS We developed the algorithm by iterative analysis of detailed observational data in 30 medical-surgical ICU patients and described its performance in this cohort and 15 patients recovering from scheduled cardiac surgery. Continuous EMG data were collected via frontal electrodes and RI data compared with modified Ramsay sedation state assessments recorded regularly by a blinded trained observer. RI performance was compared with Entropy™ across Ramsay categories to assess validity. RESULTS RI correlated well with the Ramsay category, especially for the cardiac surgery cohort (general ICU patients ρ=0.55; cardiac surgery patients ρ=0.85, both P<0.0001). Discrimination across all Ramsay categories was reasonable in the general ICU patient cohort [P(K)=0.74 (sem 0.02)] and excellent in the cardiac surgery cohort [P(K)=0.92 (0.02)]. Discrimination between 'lighter' vs 'deeper' (Ramsay 1-3 vs 4-6) was good for general ICU patients [P(K)=0.80 (0.02)] and excellent for cardiac surgery patients [P(K)=0.96 (0.02)]. Performance was significantly better than Entropy™. Examination of individual cases suggested good face validity. CONCLUSIONS RI of the frontal EMG has promise as a continuous sedation state monitor in critically ill patients. Further investigation to determine its utility in ICU decision-making is warranted.
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Rowan KM, Harrison DA, Walsh TS, McAuley DF, Perkins GD, Taylor BL, Menon DK. The Swine Flu Triage (SwiFT) study: development and ongoing refinement of a triage tool to provide regular information to guide immediate policy and practice for the use of critical care services during the H1N1 swine influenza pandemic. Health Technol Assess 2011; 14:335-492. [PMID: 21208551 DOI: 10.3310/hta14550-05] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To use, existing critical care and early pandemic, data to inform care during the pandemic influenza A 2009 (H1N1) pandemic (with a possible use for triage - if the demand for critical care seriously exceeded supply). To monitor the impact of the H1N1 pandemic on critical care services, in real time, with regular feedback to critical care clinicians and other relevant jurisdictions to inform ongoing policy and practice. DESIGN Modelling of data and cohort study. SETTING Modelling - 148 adult, general critical care units in England, Wales and Northern Ireland in the Intensive Care National Audit & Research Centre Case Mix Programme. Cohort study - 192 acute hospitals in England, Wales, Northern Ireland, Scotland and the Republic of Ireland. PARTICIPANTS Modelling - 105,397 admissions to adult, general critical care units. Cohort study - 1728 H1N1 pandemic-related admissions referred and assessed as requiring critical care. MAIN OUTCOME MEASURES Modelling - requirement for organ support and acute hospital mortality. Cohort study - survival to the end of critical care. RESULTS Modelling - cancelled or postponed, elective or scheduled surgery resulted in savings in calendar days of critical, Level 3 and advanced respiratory care of 17, 11 and 10%, respectively. These savings varied across units. Using routine, physiological variables, the best triage models, for all and for acute respiratory admissions, achieved only satisfactory concordance of 0.79 and 0.75, respectively. Application of the best model on all admissions indicated that approximately 12.5% of calendar days of critical care could be saved. Cohort study - research governance approvals were achieved for 192 acute hospitals, for 91 within 1 day of central research and development approval across the five countries. A total of 1725 cases (562 confirmed) were reported. Confirmed cases were young (mean age of 40 years), had low severity of acute illness on presentation [61% CURB-65 (confusion, urea, respiratory rate, blood pressure, age over 65 years) 0-1], but had long stays in critical care (median 8.5 days) and were likely to be ventilated (77% for median 9 days). Risk factors for acute hospital death were similar to those for general critical care admissions. CONCLUSIONS SwiFT was rapidly established. Models based on routine physiology suggested limited value for triage. More data and further modelling are warranted. The magnitude of the pandemic did not approach the worst-case scenario modelling, and UK-confirmed H1N1 cases appeared similar to those reported internationally. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Stanworth SJ, Walsh TS, Prescott RJ, Lee RJ, Watson DM, Wyncoll D. A national study of plasma use in critical care: clinical indications, dose and effect on prothrombin time. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R108. [PMID: 21466676 PMCID: PMC3219386 DOI: 10.1186/cc10129] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Revised: 03/09/2011] [Accepted: 04/05/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Fresh frozen plasma (FFP) is widely used, but few studies have described patterns of plasma use in critical care. We carried out a multicentre study of coagulopathy in intensive care units (ICUs) and here describe overall FFP utilisation in adult critical care, the indications for transfusions, factors indicating the doses used and the effects of FFP use on coagulation. METHODS We conducted a prospective, multicentre, observational study of all patients sequentially admitted to 29 adult UK general ICUs over 8 weeks. Daily data throughout ICU admission were collected concerning coagulation, relevant clinical outcomes (including bleeding), coagulopathy (defined as international normalised ratio (INR) >1.5, or equivalent prothrombin time (PT)), FFP and cryoprecipitate use and indications for transfusion. RESULTS Of 1,923 admissions, 12.7% received FFP in the ICU during 404 FFP treatment episodes (1,212 FFP units). Overall, 0.63 FFP units/ICU admission were transfused (0.11 units/ICU day). Reasons for FFP transfusion were bleeding (48%), preprocedural prophylaxis (15%) and prophylaxis without planned procedure (36%). Overall, the median FFP dose was 10.8 ml kg⁻¹, but doses varied widely (first to third quartile, 7.2 to 14.4 ml kg⁻¹). Thirty-one percent of FFP treatments were to patients without PT prolongation, and 41% were to patients without recorded bleeding and only mildly deranged INR (<2.5). Higher volumes of FFP were administered when the indication was bleeding (median doses: bleeding 11.1 ml kg⁻¹, preprocedural prophylaxis 9.8 ml kg⁻¹, prophylaxis without procedure 8.9 ml kg⁻¹; P = 0.009 across groups) and when the pretransfusion INR was higher (ranging from median dose 8.9 ml kg⁻¹ at INR ≤ 1.5 to 15.7 ml kg⁻¹ at INR >3; P < 0.001 across ranges). Regression analyses suggested bleeding was the strongest predictor of higher FFP dose. Pretransfusion INR was more frequently normal when the transfusion indication was bleeding. Overall, posttransfusion corrections of INR were consistently small unless the pretransfusion INR was >2.5, but administration during bleeding was associated with greater INR corrections. CONCLUSIONS There is wide variation in FFP use by ICU clinicians, and a high proportion of current FFP transfusions are of unproven clinical benefit. Better evidence from clinical trials could significantly alter patterns of use and modify current treatment costs.
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Lone NI, Walsh TS. Prolonged mechanical ventilation in critically ill patients: epidemiology, outcomes and modelling the potential cost consequences of establishing a regional weaning unit. Crit Care 2011; 15:R102. [PMID: 21439086 PMCID: PMC3219374 DOI: 10.1186/cc10117] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 03/06/2011] [Accepted: 03/27/2011] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The number of patients requiring prolonged mechanical ventilation (PMV) is likely to increase. Transferring patients to specialised weaning units may improve outcomes and reduce costs. The aim of this study was to establish the incidence and outcomes of PMV in a UK administrative health care region without a dedicated weaning unit, and model the potential impact of establishing a dedicated weaning unit. METHODS A retrospective cohort study was undertaken using a database of admissions to three intensive care units (ICU) in a UK region from 2002 to 2006. Using a 21 day cut-off to define PMV, incidence was calculated using all ICU admissions and ventilated ICU admissions as denominators. Outcomes for the PMV cohort (mortality and hospital resource use) were compared with the non-PMV cohort. Length of ICU stay beyond 21 days was used to model the effect of establishing a weaning unit in terms of unit occupancy rates, admission refusal rates, and healthcare costs. RESULTS Out of 8290 ICU admission episodes, 7848 were included in the analysis. Mechanical ventilation was required during 5552 admission episodes, of which 349 required PMV. The incidence of PMV was 4.4 per 100 ICU admissions, and 6.3 per 100 ventilated ICU admissions. PMV patients used 29.1% of all general ICU bed days, spent longer in hospital after ICU discharge than non-PMV patients (median 17 vs 7 days, P < 0.001) and had higher hospital mortality (40.3% vs 33.8%, P = 0.02). For the region, in which about 70 PMV patients were treated each year, a weaning unit with a capacity of three beds appeared most cost efficient, resulting in an occupancy rate of 73%, admission refusal rate at 21 days of 36%, and potential cost saving of £344,000 (€418,000) using UK healthcare tariffs. CONCLUSIONS One in every sixteen ventilated patients requires PMV in our region and this group use a substantial amount of health care resource. Establishing a weaning unit would potentially reduce acute bed occupancy by 8-10% and could reduce overall treatment costs. Restructuring the current configuration of critical care services to introduce weaning units should be considered if the expected increase in PMV incidence occurs.
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Reed MJ, Lone N, Walsh TS. Resuscitation of the trauma patient: tell me a trigger for early haemostatic resuscitation please! CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:126. [PMID: 21371347 PMCID: PMC3219305 DOI: 10.1186/cc10014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The management of trauma-related coagulopathy and haemorrhage is changing from a reactive strategy to a proactive early intervention with blood products and haemostatic agents. Although major haemorrhage and massive transfusion are associated with higher mortality, the pattern of this association with modern trauma care is poorly described. In addition, early predictors of massive transfusion, which might trigger a proactive haemostatic resuscitation strategy, are not currently available. We review recent literature relating to predictors of massive transfusions and the relationship between transfusion and mortality.
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Watson DM, Stanworth SJ, Wyncoll D, McAuley DF, Perkins GD, Young D, Biggin KJ, Walsh TS. A national clinical scenario-based survey of clinicians' attitudes towards fresh frozen plasma transfusion for critically ill patients. Transfus Med 2010; 21:124-9. [PMID: 21062383 DOI: 10.1111/j.1365-3148.2010.01049.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND It is known that 20-30% of fresh frozen plasma (FFP) is used in intensive care units (ICUs), but little is known about variations in decision making between clinicians in relation to coagulopathy management. Our aim was to describe ICU clinicians' beliefs and practice in relation to FFP treatment of non-bleeding coagulopathic critically ill patients. METHODS Two patient-based scenarios were developed and sent to 2700 members of two UK intensive care professional societies. Scenario 1 was a non-bleeding septic patient with coagulopathy; scenario 2 was a non-bleeding critically ill patient with hepatic cirrhosis and coagulopathy. Responses were sought in relation to FFP prophylaxis, and prior to central venous cannulation. A supplementary question asked clinicians' view of prophylaxis in relation to other ICU procedures. RESULTS Two-thousand-and-seven-hundred clinicians were surveyed from whom 601 responses were received (22·3% response rate). For scenario 1 52% of respondents stated that they would never routinely administer prophylactic FFP, but this decreased to 9% when central venous cannulation was planned (P < 0·01). There was wide variation in the 'trigger' INR (international normalised ratio) value used prior to central vein cannulation, the most common range being 2·0-2·4. For scenario 2, responses were very similar. More than 80% of clinicians stated that they would routinely treat coagulopathy prior to lumbar puncture, epidural catheterisation, intracranial pressure monitoring and tracheostomy; and 54% prior to chest drain insertion. CONCLUSION Our survey demonstrated a wide range of responses consistent with important variations in clinical practice and substantial clinical uncertainty in relation to FFP treatment for non-bleeding ICU patients.
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Monaco F, Drummond GB, Ramsay P, Servillo G, Walsh TS. Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients? Br J Anaesth 2010; 105:326-33. [PMID: 20656695 DOI: 10.1093/bja/aeq184] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vt(exp)), respiratory rate (f), minute volume (MV(exp)), rapid shallow breathing index (f/Vt), inspired-expired oxygen concentration difference [(I-E)O(2)], and end-tidal carbon dioxide concentration (Pe'(co(2))) at the end of a weaning trial to predict early weaning outcomes. METHODS Seventy-three patients who required >24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H(2)O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated. RESULTS Pre-test probability for achieving the outcome was 44% in the cohort (n=32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H(+) concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I-E]O(2) and Pe'(co(2)) had weak discriminatory power [area under the ROC curve: [I-E]O(2) 0.64 (P=0.03); Pe'(co(2)) 0.63 (P=0.05)]. Using best cut-off values for [I-E]O(2) of 5.6% and Pe'(co(2)) of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%. CONCLUSIONS In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.
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Walsh TS. Red cell transfusion triggers in critically ill patients: time for some new TRICCs? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:170. [PMID: 20587005 PMCID: PMC2911743 DOI: 10.1186/cc9043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Current evidence suggests that critically ill patients tolerate anaemia well and that blood transfusions may increase the risk of adverse outcomes. Dr Sakr and colleagues present a contradictory analysis of a surgical ICU cohort, finding an association between blood transfusions and lower hospital mortality after adjustment for a range of potential confounders. Analyses of this kind are interesting and provocative, but are limited by residual confounding and bias by indication. The data emphasise the need for additional high quality trials of transfusion practice in critical care.
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Salisbury LG, Merriweather JL, Walsh TS. The development and feasibility of a ward-based physiotherapy and nutritional rehabilitation package for people experiencing critical illness. Clin Rehabil 2010; 24:489-500. [DOI: 10.1177/0269215509360639] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To investigate ward-based rehabilitation after critical illness and undertake a pilot study exploring the feasibility of delivering enhanced physiotherapy and nutritional rehabilitation. Design: Service evaluation (part A) and pilot feasibility randomized controlled trial (part B). Setting: Hospital inpatient wards following discharge from intensive care. Participants: Part A involved 24 people with an intensive care stay of four days or more. Part B involved 16 participants randomized into a control (n = 8) or intervention (n = 8) group. Interventions: Part A defined the current ‘standard’ physiotherapy and nutritional interventions. In part B the control group received this ‘standard’ service while the intervention group received this ‘standard’ service plus enhanced rehabilitation. Main measures: Part A collected process outcomes of current interventions and outcomes that included calorie and protein intake and the Rivermead Mobility Index. In part B process outcomes determined differences between groups. Outcomes included those undertaken in part A plus an incremental shuttle test, handgrip dynamometry and visual analogue scales. Results: Part A found low levels of ward-based physiotherapy (walking and transfer practice once per week) and dietetic input (0.8 visits per week). Part B found an increased frequency of both physiotherapy (P = 0.002) and dietetic (P = 0.001) visits in the intervention group. Physical and nutritional outcomes were suitable for use after critical illness, but no statistically significant differences were found between groups. Power calculations indicated 100 participants per group would be required for a definitive study. Conclusions: This feasibility pilot work has informed the design of a larger study to evaluate enhanced rehabilitation following critical illness.
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