Intensive and critical care

Intensive care unit (ICU) referrals and admissions at a district general hospital (DGH) in light of the COVID-19 pandemic (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Naughton E.; *Pradhan N.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: The COVID-19 pandemic has led to an increase in ICU referrals and admissions across the UK during 2020 [1]. Intensive care beds are a limited and expensive resource and decisions on patient admission are often very challenging [2]. Proformas help to standardise documentation and decision logging during patient referrals [3]. They provide easily accessible evidence in case of a future referral and allow audit of decision-making processes. A preliminary survey of doctors working in a DGH ICU was undertaken to assess the current referral and admission process in expectation of an increased volume of work.
Objective(s): As a result of the survey, three main areas for improvement were identified: 1. To maintain a record of all ICU referrals and decision-making processes 2. To reduce the time taken for documentation of referrals and admissions 3. To improve the quality and appropriateness of referrals from parent specialities Methods: A proforma was designed for dual use as a referral and admission document. All referrals were recorded on paper and staff received training on how to apply the proforma. After assessment of each referral, irrespective of admission outcome, a completed copy of the proforma was placed in both the patient's notes and a dedicated referrals folder. After one month, a further survey was designed to assess the response postimplementation of the proforma. All referrals made over a threemonth period between April and June 2020 were audited.
Result(s): The initial survey received 12 responses. Prior to the COVID-19 pandemic, documentation of any referral or admission took on average 10-15 minutes. All survey participants felt that referring teams did not have a good understanding of the role of ICU care and estimated that up to 40% of all referrals received were inappropriate. The follow-up survey received 14 responses. Implementation of the proforma reduced the time taken to document a referral or admission on average by 5-10 minutes. Twelve participants found the proforma a useful aid, helping to provide clear documentation and ease communication between ICU team members. Less than 9% of the referrals made between April and June 2020 were admitted to ICU with over 32% of referrals deemed unsuitable for further escalation. Approximately 50% of referrals were made by registrars, with 13% discussed by consultants. The median age of patients referred was 67.5 and the most common reason was for respiratory deterioration.
Conclusion(s): This quality improvement project successfully reduced the time taken to document ICU referrals and admissions. Use of a proforma has provided many benefits, including standardisation of documentation, decision logging and improvement of intra-and inter-team communication. Only a small proportion of patients referred to ICU have been suitable for admission. A teaching session is being designed so that referral information can be fed-back to parent specialties. Referrals will be reaudited after this. Data analysis of this project has been limited by incomplete proforma documentation from participating users.

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A Tidal volume calculator to improve lung protective ventilation in COVID-19 related Acute Respiratory Distress Syndrome (ARDS) (2020)

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Type of publication:
Conference abstract

Author(s):
*Blair J.; *Hester S.; Baldwin A.; Ali T.

Citation:
Intensive Care Medicine Experimental; 2020; vol. 8

Abstract:
Introduction: Routine use of lower tidal volumes (TVs) for the mechanical ventilation of patients with ARDS results in decreased mortality and increases the number of days without ventilator use [1]. Severe COVID-19 pneumonia has been associated with the development of ARDS as characterised by the Berlin definition [2]. A multi-centre preliminary audit was undertaken to identify whether ventilated COVID-19 related ARDS patients were receiving optimal TVs, as recommended by the Faculty of Intensive Care Medicine (FICM) and Intensive Care Society (ICS) ARDS management guidelines [3]. Objective(s): As a result of the audit, three main areas for improvement were identified. 1. To achieve accurate calculations for ideal body weight (IBW) and target TV 2. To improve documentation of IBW and target TV 3. To achieve TVs no greater than 6 ml/kg Methods: A 'tidal volume calculator' tool was developed using Microsoft Excel, which was simple, colour coded and kept on all Intensive Care Unit (ICU) computer desktops. This tool was designed to use height to calculate IBW and, if the patient's height was unavailable, could also be utilised to calculate height from ulna length. IBW was subsequently used to calculate a target TV. Staff received training on how to apply the tool. Two snapshot audits were carried out in April and May 2020 at two ICUs. The first was conducted prior to the tool's introduction with the second two weeks after its implementation. All patients receiving mechanical ventilation, except those spontaneously breathing, were included. Data was extracted from patient notes, charts and ventilator settings. Result(s): The initial audit included 14 patients. Six patients did not have an IBW documented. Three patients had documented IBWs that were 12 kg, 15 kg and 23 kg greater than the weight calculated using the tool, leading to increased tidal volume targets. Only three patients were achieving TVs of 4-6 ml/kg. Eleven patients were achieving a TV greater than 6 ml/kg, with two of these achieving a TV of greater than 8 ml/kg. The follow-up audit included ten patients. This revealed that all patients had an IBW clearly documented. Moreover, nine patients were achieving TVs within 4-6 ml/kg, with only one patient found to be achieving a TV greater than 6 ml/kg. Conclusion(s): This audit cycle revealed that initially adherence to lung protective ventilation and documentation of IBW was poor. In some instances, documented IBW was vastly different to the calculated IBW, suggesting that in these situations actual body weight may have been used. In a time when clinicians were being redeployed to support ICU, this simple tool was shown to support staff by clearly calculating and displaying IBW and target TV for reference. This directly led to improved adherence to lung protective ventilation and optimisation of patient care. Limitations include that no consideration was made for overall patient outcome, and only a snapshot of achieved TVs from ventilators were recorded; daily/weekly trends were not studied.

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Developing an intervention around referral and admissions to intensive care: a mixed-methods study (2019)

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Type of publication:
Journal article

Author(s):
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C & Slowther A.

Study involved patients at Shrewsbury and Telford Hospital NHS Trust

Citation:
Health Services and Delivery Research 2019, Vol 7, Issue 39

Abstract:
Background: Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.
Objectives: To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.
Methods: A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.
Results: Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.
Limitations: Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.
Conclusions: Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.
Future work: Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.
Study registration: The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.
Funding: The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.

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Mortality of in-patient medical admissions to a DGH Critical Care Unit (2019)

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Type of publication:
Conference abstract

Author(s):
*Sunil Tailor, *Ade Adiamou, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019. Intensive Care Society Conference. Birmingham December 9-12.

Abstract:
Increasing clinical demand and reorganisation of hospital services may result in “stable” medical in-patients being “cohorted” into hospital locations without ready access to critical care services on site. The NEWS tool is recognised to provide warning of deterioration and a trigger for escalation of care [1]. Current EWS tools perform well for predicting death and cardiac arrest within 48 hours, although the impact on in-hospital health outcomes and utilization of resources remains uncertain [2]. In a retrospective case review, we examined the outcome of medical patients who had been hospital in-patients for more than 48 hours, whose condition deteriorated, requiring admission to our critical care unit (Princess Royal Hospital). The aim was to identify “red flag” observations for their deterioration and to measure mortality (overall: hospital + 30-day) in this patient group. During 2016-17 we identified 51 patients, of whom 39 patients were analysed because of a complete data set. We classified 48% (19 patients )as hot: defined as having a NEWS of 5 or more on one or more occasions in the 48-hours prior to ITU admission.
52% (21 patients) were classified as warm; defined as having a NEWS no greater than 4 on one or more occasions in the 48hr prior to ITU admission.
Red flag parameters (individual score of 3) were: Respiratory rate <8 or >25; SpO2 < 91%; temperature < 35C; SBP < 90 or > 220 mmHg; HR < 40 or > 131; AVPU: VPU.
Results:

  • The most common predictive red flag indicator for ITU admission was a raised respiratory rate.
  • 11 of the 39 patients did not score any red flag indicators. The mortality of this group was 33%.
  • The mortality rate of the 39 patients was 66%. The mortality for hot and warm classifications was 71% and 46% respectively.
  • The majority (>80%) of patients were aged 51-80 years .
  • The mean duration of ITU stay was 7.4 days (warm) vs 9.5 days (hot).
  • Over the same time period, ICNARC data demonstrated that 80% of all admissions to the ITU were non-surgical; overall ITU and hospital mortality was 15.7% and 22.5% respectively.

Conclusions

  • Medical inpatients with a persistently high NEWS of 5 or more during 48 hrs prior to ITU admission had a very high 30-day mortality despite ITU care.
  • 11 patients had no red flag indicators in the 48 hours prior to ITU admission despite their subsequent deterioration.
  • There are significant resource implications in managing such patients.
  • Care must be taken in defining stability in respect of medical in-patients in order to avoid later deterioration.

Limitations: Not all patients could be analysed because of incomplete data.

References:

  1. Thompson R. National Early Warning Score (NEWS). Report of a Working Party, Royal College of Physicians,UK, July 2012.
  2. Beth Smith M, Chiovaro J, O'Neil M, et al. Early Warning System Scores for Clinical Deterioration in Hospitalized Patients: A Systemic Review. Ann Am Thorac Soc 2014; 11:1454-1465.

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Severe Hypercalcaemia in Intensive Care: An unusual cause (2019)

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Type of publication:
Conference abstract

Author(s):
*Zi Hao Reuel Heng, *Rhys Parry, *Omu Davies, *Roger Slater

Citation:
State of the Art 2019, Intensive Care Society Conference, Birmingham, December 9-12.

Abstract:
Background: Severe hypercalcemia is defined as serum calcium > 3.5 mmol/l.
Major causes of hypercalcemia in adults include primary hyperparathyroidism, milk-alkali syndrome and malignant neoplasms. Neoplasms cause hypercalcaemia either by direct invasion (metastasis) or through factors that stimulate osteoclasts (Parathyroid hormone related peptide or PTHrP). Very rarely a benign tumour can be responsible. Clinical features of hypercalcemia correlate with degree and rapidity of rise of serum calcium. Severe hypercalcemia is associated with neurological, renal and gastrointestinal symptoms.
The differential diagnosis of the cause is determined by measuring parathyroid hormone (PTH) levels.
The case: A 33-year-old woman 37/52 pregnant presented with epigastric pain, vomiting, proteinuria and hypertension and a deteriorating GCS (11/15). A CT head was normal. Blood showed hyperuricaemia and acute kidney injury. She was transferred to the operating room for caesarean section with suspected fulminating pre-eclampsia following a fall in GCS to 8. Immediately prior to general anaesthetic induction she had a generalized seizure. She was induced, intubated and commenced on IV magnesium and labetolol. Following successful delivery, a large pedunculated fibroid was noted on the left side of the uterus. She was transferred to intensive care sedated, intubated and ventilated. Routine blood testing demonstrated severe hypercalcaemia, corrected serum calcium of 5.05 mmol/l. PTH was at the lower limit at 1.3 pmol/l (normal range 1.3 – 7.6 pmol/l). Treatment consisted of IV rehydration with 0.9% sodium chloride 4 litres in 24hr, IV Pamidronate (a bisphosphonate) 60mg over 2 hours. Over the next 3 days the serum calcium returned to normal. A literature search uncovered 3 reports of benign uterine leiomyomas having been the source of ectopic PTHrP leading to hypercalcaemia [1,2,3]. In this case, the uterine fibroid was presumed to have been the source of PTHrP. Unfortunately, direct measurement of PTHrP was not possible at the time of presentation. In view of the fact that the calcium had returned to normal with medical treatment and post-delivery, it was decided to defer further surgery. The patient was successfully weaned from ventilatory support after 5 days. She was monitored and calcium remained within normal limits. 3/12 later the fibroid was removed. The histology showed a mitotically active smooth muscle leiomyoma.
Conclusion: Uterine leiomyoma can rarely be a cause of hypercalcaemia in the critically ill obstetric patient. Severe hypercalcaemia can present in a similar manner to pre-eclampsia, and can worsen pre-eclampsia. Intensivists need to be aware of this condition.
Discussion: The clinical picture was strongly suggestive of severe hypercalcaemia associated with a uterine fibroid. The history did not reveal ingestion of excessive calcium-containing antacids sufficient to cause hypercalcaemia. A hypercalcaemic crisis can occur during pregnancy; the immediate postpartum period being the most likely time,. At this time, relative dehydration and an abrupt decrease in placental transport of calcium to the foetus can coexist. Severe hypercalcaemia can rarely produce seizures, the mechanism is thought to be due to cerebro-vasospasm.
References
1.Ravakhah K, Gover A, Mukunda B. Humoral Hypercalcemia Associated with a Uterine Fibroid. Annals of Internal Medicine 1999; 130: 702.
2.Tarnawa E, Sullivan S, Underwood P et al. Severe hypercalcemia Associated with Uterine Leiomyoma in Pregnancy. Obstetrics & Gynecology 2011;117: 473-476
3.Garcha A, Gumaste P, Cherian S et al. Hypercalcemia: An Unusual Manifestation of Uterine Leiomyoma. Case Reports in Medicine 2013; Article ID 815252.

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Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study (2019)

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Type of publication:
Journal article

Author(s):
Claireaux H.A.; Antoniou I.; Dean R.; Davies N.; Trecarten S.; Henderson I.; Holmes C.; Wylie J.; Shuttleworth R.H.; Jindal A.; Hughes F.; Gouda P.; McNamee L.; Fleck R.; Hanrahan M.; Karunakaran P.; Chen J.H.; Sykes M.C.; Sethi R.K.; Suresh S.; Patel P.; Patel M.; Varma R.K.; Mushtaq J.; Gundogan B.; Bolton W.; Mohan M.; Khan T.; Burke J.; Morley R.; Favero N.; Adams R.; Thirumal V.; Kennedy E.D.; Ong K.K.; Tan Y.H.; Gabriel J.; Bakhsh A.; Low J.Y.L.; Yener A.; Paraoan V.; Preece R.; Tilston T.W.; Cumber E.; Dean S.; Ross T.; McCance E.; Amin H.; Satterthwaite L.; Clement K.D.; Gratton R.; Mills E.D.; Chiu S.M.; Hung G.; Rafiq N.M.; Hayes J.D.B.; Robertson K.L.; Dynes K.; Huang H.C.; Assadullah S.; Duncumb J.W.; Moon R.D.C.; Poo S.X.; Mehta J.K.; Joshi K.R.; Callan R.; Norris J.M.; Chilvers N.J.; Keevil H.; Jull P.; Mallick S.; Elf D.; Carr L.; Player C.; Barton E.C.; Martin A.L.; Ratu S.G.; Roberts E.J.; Phan P.N.; Dyal A.R.; Rogers J.E.; Henson A.D.; Reid N.B.; Burke D.; Culleton G.; Lynne S.; Mansoor S.; Brennan C.; Blessed R.; Holloway C.; Hill A.; Goldsmith T.; Mackin S.; Kim S.; Woin E.; Brent G.; Coffin J.; Ziff O.; Momoh Z.; Debenham R.; Ahmed M.; Yong C.S.; Wan J.C.; Copley H.C.; Raut P.; Chaudhry F.I.; Nixon G.; Dorman C.; Tan R.; Kanabar S.; Canning N.; Dolaghan M.; Bell N.; McMenamin M.; Chhabra A.; Duke K.; Turner L.; Patel T.; Chew L.S.; Mirza M.; Lunawat S.; Oremule B.; Ward N.; Khan M.; Tan E.T.; Maclennan D.; McGregor R.J.; Chisholm E.G.; Griffin E.J.; Bell L.; Hughes B.A.; Davies J.; Haq H.; Ahmed H.; Ungcharoen N.; Whacha C.; Thethi R.; Markham R.M.; Lee A.H.Y.; Batt E.; Bullock N.P.; Francescon C.T.; Davies J.E.; Shafiq N.M.; Zhao J.; Vivekanantham S.; Barai I.; Allen J.L.Y.; Marshall D.C.; McIntyre C.J.; Wilson H.C.P.; Ashton A.J.; Lek C.; Behar N.; Davis-Hall M.; Seneviratne N.; Esteve L.; Sirakaya M.; Ali S.; Pope S.; Ahn J.S.; Craig-McQuaide A.; Gatfield W.A.; Leong S.; Demetri A.M.; Kerr A.L.; Rees C.; Loveday J.; Liu S.; Wijesekera M.; Maru D.; Attalla M.; Smith N.; Brown D.; Sritharan P.; Shah A.; Charavanamuttu V.; Heppenstall-Harris G.; Ng K.; Raghvani T.; Rajan N.; Hulley K.; Moody N.; Williams M.; Cotton A.; Sharifpour M.; Lwin K.N.; Bright M.; Chitnis A.R.; Abdelhadi M.; Semana A.D.; Morgan F.; Reid R.; Dickson J.; Anderson L.; McMullan R.; Ahern N.; Asmadi A.; Anderson L.B.; Boon Xuan J.L.; Crozier L.; McAleer S.; Lees D.M.; Adebayo A.A.; Das M.; Amphlett A.H.; Al-Robeye A.; Valli A.; Khangura J.; Winarski A.; Ali A.; Woodward H.; Gouldthrope C.; Turner M.; Sasapu K.; Tonkins M.; Wild J.R.L.; Robinson M.; Hardie J.; Heminway R.; Narramore R.; Ramjeeawon N.; Hibberd A.; Winslow F.; Ho W.; Chong B.F.; Lim K.; Ho S.; Crewdson J.A.; Singagireson S.; Kalra N.; Koumpa F.; Jhala H.; Soon W.C.; Karia M.; Rasiah M.G.; Xylas D.; Gilbert H.; Sundar-Singh M.; Wills J.; Akhtar S.; Patel S.; Hu L.; Brathwaite-Shirley C.; Nayee H.; Amin O.; Rangan T.; Turner E.J.H.; McCrann C.; Shepherd R.; Patel N.; Prest-Smith J.; Auyoung E.; Murtaza A.; Coates A.; Prys-Jones O.; King M.; Gaffney S.; Dewdney C.J.; Nehikhare I.; Lavery J.; Bassett J.; Davies K.; Ahmad K.; Collins A.; Acres M.; Egerton C.; Cheng K.; Chen X.; Chan N.; Sheldon A.; Khan S.; Empey J.; Ingram E.; Malik A.; Johnstone M.; Goodier R.; Shah J.P.; Giles J.E.; Sanders J.A.; McLure S.W.; Pal S.; Rangedara A.; Baker A.N.; Asbjoernsen C.A.; Girling C.; Gray L.; Gauntlett L.; Joyner C.; Qureshi S.; Mogan Y.P.; Ng J.C.K.; Kumar A.N.; Park J.H.; Tan D.; Choo K.P.; Raman K.P.; Buakuma P.; Xiao C.; Govinden S.; Thompson O.D.; Charalambos M.A.; Brown E.; Karsan R.B.; Dogra T.; Bullman L.M.; Dawson P.M.; Frank A.L.; Abid H.; Tung L.; Qureshi U.; Tahmina A.; Matthews B.W.; Harris R.T.; O'Connor A.; Mazan K.; Iqbal S.; Stanger S.A.; Thompson J.D.; Sullivan J.A.L.; Uppal E.; MacAskill A.; Bamgbose F.A.; Neophytou C.; Carroll A.F.; Rookes C.W.; Datta U.; Dhutia A.J.; Rashid S.; Ahmed N.; Lo T.; Bhanderi S.; Blore C.D.; Ahmed S.; Shaheen H.; Abburu S.; Majid S.; Abbas Z.; Talukdar S.S.; Burney L.J.; Patel J.B.; Al-Obaedi O.; Roberts A.W.; Mahboob S.; Singh B.; Sheth S.; Karia P.; Prabhudesai A.; Kow K.; Koysombat K.; Wang S.; Morrison P.; Maheswaran Y.; Keane P.; Copley P.C.; Brewster O.; Xu G.X.; Harries P.; Wall C.; AlMousawi A.; Bonsu S.; Cunha P.; Ward T.; Paul J.; Nadanakumaran K.; Tayeh S.; Holyoak H.; Remedios J.; Theodoropoulou K.; Luhishi A.; Jacob L.; Long F.; Atayi A.; Sarwar S.; Parker O.; Harvey J.; Ross H.; Rampal R.; Thomas G.; Vanmali P.; McGowan C.; Stein J.; Robertson V.; Carthew L.; Teng V.; Fong J.; Street A.N.; Thakker C.E.; O'Reilly D.; Bravo M.; Pizzolato A.; Khokhar H.A.; Ryan M.; Cheskes L.; Carr R.; Salih A.E.; Bassiony S.; Yuen R.; Chrastek D.; Rosen O'Sullivan H.; Amajuoyi A.; Wang A.; Sitta O.; Wye J.; Qamar M.A.; Major C.; Kaushal A.; Morgan C.; Petrarca M.; Allot R.; Verma K.; Dutt S.; Chilima C.P.; Peroos S.; Kosasih S.R.; Chin H.; Ashken L.; Pearse R.J.; O'Loughlin R.A.; Menon A.; Singh K.; Norton J.; Sagar R.; Jathanna N.; Rothwell L.; Watson N.; Harding F.; Dube P.; Khalid H.; Punjabi N.; Sagmeister M.; Gill P.; Shahid S.; Hudson-Phillips S.; George D.; Ashwood J.; Lewis T.; Dhar M.; Sangal P.; Rhema I.A.; Kotecha D.; Afzal Z.; Syeed J.A.; Prakash E.; Jalota P.; Herron J.; Kimani L.; Delport A.; Shukla A.; Agarwal V.; Parthiban S.; Thakur H.; Cymes W.; Rinkoff S.; Turnbull J.A.; Hayat M.; Darr S.; Khan U.; Lim J.; Higgins A.; Lakshmipathy G.; Forte B.; Canning E.; Jaitley A.; Lamont J.; Toner E.; Ghaffar A.; McDowell M.; Salmon D.; O'Carroll O.; Khan A.; Kelly M.E.; Clesham K.; Palmer C.; Lyons R.; Bell A.; Chin R.; Waldron R.M.; Trimble A.; Cox S.E.; Ashfaq U.; Campbell J.; Holliday R.B.S.; McCabe G.; Morris F.; Priestland R.; Vernon O.K.; Ledsam A.; Vaughan R.; Lim D.; Bakewell Z.R.; Hughes R.K.; Koshy R.M.; Jackson H.R.; Narayan P.; Cardwell A.E.; Jubainville C.L.; Arif T.; Elliott L.E.; Gupta V.; Bhaskaran G.; Odeleye A.; Ahmed F.; Shah R.; Pickard J.; Suleman Y.N.; North A.S.; McClymont L.F.; Hussain N.; Ibrahim I.; Ng G.S.; Wong V.; Lim A.E.; Harris L.N.; Tharmachandirar T.; Mittapalli D.; Patel V.; Lakhani M.; Bazeer H.Z.; Narwani V.; Sandhu K.K.; Wingfield L.R.; Gentry S.; Adjei H.; Bhatti M.; Braganza L.; Barnes J.; Mistry S.; Chillarge G.; Stokes S.; Cleere J.; Wadanamby S.; Bucko A.M.; Meek J.; Boxall N.; Heywood E.G.; Wiltshire J.J.; Toh C.; Ward A.E.; Shurovi B.N.; Horth D.; Patel B.Y.; Ali B.; Spencer T.; Axelson T.; Kretzmer L.; Chhina C.; Anandarajah C.; Fautz T.; Horst C.; Thevathasan A.A.; Ng J.Q.; Hirst F.; Brewer C.F.; Logan A.E.; Lockey J.W.; Forrest P.R.; Keelty N.; Wood A.D.; Springford L.R.; Avery P.; Schulz T.M.; Bemand T.P.; Howells L.; Collier H.; Khajuria A.; Tharakan R.G.; Parsons S.; Buchan A.M.; McGalliard R.J.; Mason J.D.; Cundy O.J.; Li N.; Redgrave N.A.; Watson R.P.; Pezas T.P.; Dennis Y.F.; Segall E.; Hameed M.; Lynch A.S.; Chamberlain M.; Peck F.S.; Neo Y.N.; Russell G.; Elseedawy M.; Lee S.; Foster N.L.; Soo Y.H.; Puan L.; Dennis R.; Goradia H.; Qureshi A.; Osman S.; Reeves T.; Dinsmore L.; Marsden M.; Lu Q.; Pitts-Tucker T.; Dunn C.E.; Walford R.A.; Heathcote E.; Martin R.; Pericleous A.; Brzyska K.; Reid K.G.; Williams M.R.; Wetherall N.; McAleer E.; Thomas D.; Kiff R.; Milne S.; Holmes M.J.V.; Bartlett J.; Lucas de Carvalho J.; Bloomfield T.; Tongo F.; Bremner R.H.; Yong N.; Atraszkiewicz B.A.; Mehdi A.; Tahir M.; Sherliker G.X.J.; Tear A.K.; Pandey A.; Broyd A.; Omer H.M.; Raphael M.; Chaudhry W.W.; Shahidi S.; Jawad A.S.; Gill C.K.; Fisher I.H.; Adeleja I.; Clark I.J.; Aidoo-Micah G.E.; Stather P.W.; Salam G.J.; Glover T.E.; Deas G.; Sim N.K.; Obute R.D.; Wynell-Mayow W.M.; Sait M.S.; Mitha N.; de Bernier G.L.; Siddiqui M.; Shaunak R.; Wali A.; Cuthbert G.; Bhudia R.; Webb E.; Shah S.; Ansari N.; Perera M.; Kelly N.; McAllister R.; Stanley G.H.; Keane C.P.; Shatkar V.; MaxwellArmstrong C.; Henderson L.A.; Maple N.; Manson R.; Adams R.D.; Semple E.; Mills M.; Daoub A.; Marsh A.; Ramnarine A.; Hartley J.; Malaj M.; Jewell P.D.; Whatling E.A.; Hitchen N.; Chen M.; Goh B.; Fern J.; Rogers S.; Derbyshire L.; Robertson D.T.; Abuhussein N.; Deekonda P.; Abid A.; Harrison P.L.M.; Aildasani L.; Turley H.; Sherif M.A.; Pandey G.; Filby J.J.; Johnston A.; Burke E.; Mohamud M.; Gohil K.; Tsui A.Y.; Singh R.; Lim S.J.; O'Sullivan K.; McKelvey L.L.; O'Neill S.; Roberts H.F.; Brown F.S.; Cao Y.; Buckle R.T.; Liew Y.; Sii S.; Ventre C.M.; Graham C.J.; Filipescu T.; Yousif A.; Dawar R.; Wright A.; Peters M.; Varley R.; Owczarek S.; Hartley S.; Khattak M.; Iqbal A.; Ali M.; Durrani B.; Narang Y.; Bethell G.S.; Horne L.; Pinto R.; Nicholls K.; Kisyov I.; Torrance H.D.; English W.; Lakhani S.M.; Ashraf S.F.; Venn M.; Elangovan V.; Kazmi Z.; Brecher J.; Sukumar S.; Mastan A.; Mortimer A.; Parker J.; Boyle J.; Elkawafi M.; *Beckett J.; *Mohite A.; *Narain A.; *Mazumdar E.; *Sreh A.; *Hague A.; *Weinberg D.; *Fletcher L.; *Steel M.; Shufflebotham H.; Masood M.; Sinha Y.; Jenvey C.; Kitt H.; Slade R.; Craig A.R.; Deall C.; Reakes T.; Chervenkoff J.; Strange E.; O'Bryan M.; Murkin C.; Joshi D.; Bergara T.; Naqib S.; Wylam D.; Scotcher S.E.; Hewitt C.M.; Stoddart M.T.; Kerai A.; Trist A.J.; Cole S.J.; Knight C.L.; Stevens S.; Cooper G.E.; Ingham R.; Dobson J.; O'Kane A.; Moradzadeh J.; Duffy A.; Henderson C.; Ashraf S.; McLaughin C.; Hoskins T.C.; Reehal R.S.; Bookless L.R.; McLean R.C.; Stone E.J.; Wright E.V.; Abdikadir H.R.; Roberts C.; Spence O.; Srikantharajah M.; Ruiz E.M.; Matthews J.H.; Gardner E.; Hester E.; Naran P.; Simpson R.; Minhas M.; Cornish E.; Semnani S.A.; Rojoa D.; Radotra A.; Eraifej J.; Eparh K.; Smith D.N.E.; Mistry B.D.; Hickling S.L.; Din W.; Liu C.; Mithrakumar P.; Mirdavoudi V.; Rashid M.; Mcgenity C.; Hussain O.; Kadicheeni M.; Gardner H.; Anim-Addo N.; Pearce J.; Aslanyan A.; Ntala C.; Sorah T.; Parkin J.; Alizadeh M.; White A.; Edozie F.; Johnston J.; Kahar A.; Navayogaarajah V.; Patel B.; Carter D.; Khonsari P.; Burgess A.; Kong C.; Ponweera A.; Cody A.; Tan Y.; Ng A.Y.L.; Croall A.; Allan C.; Ng S.; Raghuvir V.; Telfer R.; Greenhalgh A.D.; McKerr C.N.; Edison M.A.; Patel B.A.; Dear K.; Hardy M.R.; Williams P.; Hassan S.; Sajjad U.; O'Neill E.M.; Lopes S.; Healy L.; Jamal N.; Tan S.; Lazenby D.; Husnoo S.B.; Beecroft S.; Sarvanandan T.; Weston C.; Bassam N.; Rabinthiran S.; Hayat U.; Ng L.; Varma D.; Sukkari M.; Mian A.; Omar A.; Kim J.W.; Sellathurai J.; Mahmood J.; O'Connell C.; Bose R.; Heneghan H.; Lalor P.; Matheson J.; Doherty C.; Cullen C.; Cooper D.; Angelov S.; Drislane C.; Smith A.C.D.; Kreibich A.; Palkhi E.; Durr A.; Lotfallah A.; Gold D.; Mckean E.; Dhanji A.; Anilkumar A.; Thacoor A.; Siddiqui Z.H.; Lim S.; Piquet A.; Anderson S.M.; McCormack D.R.; Gulati J.; Ibrahim A.; Murray S.E.; Walsh S.L.; McGrath A.; Ziprin P.; Chua E.Y.; Lou C.N.; Bloomer J.; Paine H.R.; Osei-Kuffour D.; White C.J.; Szczap A.; Gokani S.; Patel K.; Malys M.K.; Reed A.; Torlot G.E.; Cumber E.M.; Charania A.; Ahmad S.; Varma N.; Cheema H.; Austreng L.; Petra H.; Chaudhary M.; Zegeye M.I.; Cheung F.; Coffey D.; Heer R.S.; Singh S.; Seager E.; Cumming S.; Suresh R.S.; Verma S.; Ptacek I.B.; Gwozdz A.M.; Yang T.; Khetarpal A.A.; Shumon S.; Fung T.M.P.; Leung W.; Kwang P.; Chew L.; Loke W.; Curran A.; Chan C.; McGarrigle C.; Mohan K.; Cullen S.; Wong E.; Toale C.; Collins D.; Keane N.; Traynor B.P.; Shanahan D.; Yan A.; Jafree D.J.; Topham C.; Mitrasinovic S.; Omara S.; Bingham G.; Lykoudis P.M.; Miranda B.H.; Whitehurst K.; Kumaran G.; Devabalan Y.; Aziz H.; Shoa M.; Dindyal S.; Yates J.A.; Bernstein I.; Rattan G.; Coulson R.; Stezaker S.; Isaac A.; Salem M.; McBride A.; McFarlane H.; Yow L.; MacDonald J.; Bartlett R.D.; Turaga S.; White U.; Liew W.; Yim N.; Ang A.; Simpson A.; McAuley D.; Craig E.; Murphy L.; Shepherd P.; Kee J.Y.; Abdulmajid A.; Chung A.; Warwick H.L.; Livesey A.; Holton P.; Theodoreson M.D.; Jenkin S.L.; Turner J.; Entwisle J.H.; Marchal S.T.; O'Connor S.; Blege H.K.; Aithie J.M.; Sabine L.M.; Stewart G.E.; Jackson S.; Kishore A.; Lankage C.M.; Acquaah F.; Joyce H.L.; McKevitt K.L.; Coffey C.J.; Fawaz A.S.; Dolbec K.S.; O'Sullivan D.A.; Geraghty J.M.; Lim E.; Bolton L.; FitzPatrick D.; Robinson C.; Ramtoola T.; Collinson S.; Grundy L.; McEnhill P.M.; Harbhajan Singh G.S.; Loughran D.; Golding D.M.; Keeling R.E.; Williams R.P.; Whitham R.D.J.; Yoganathan S.; Nachiappan R.; Egan R.J.; Owasil R.; Kwan M.L.; He A.; Goh R.W.; Bhome R.; Wilson H.; Teoh P.J.; Raji K.; Jayakody N.; Matthams J.; Chong J.; Luk C.Y.; Greig R.J.; Trail M.; Charalambous G.; Rocke A.S.; Gardiner N.; Bulley F.; Warren N.; Brennan E.; Fergurson P.; Wilson R.; Whittingham H.; Brown E.J.; Khanijau R.; Gandhi K.; Morris S.; Boulton A.J.; Chandan N.; Barthorpe A.E.; Maamari R.; Sandhu S.; McCann M.; Higgs L.; Balian V.; Reeder C.; Diaper C.; Sale T.; Ali H.; Archer C.H.; Clarke A.K.; Heskin J.; Hurst P.C.; Farmer J.D.; O'Flynn L.D.; Doan L.; Shuker B.A.; Stott G.D.; Vithanage N.A.; Hoban K.A.; Nesargikar P.N.; Kennedy H.R.; Grossart C.M.; Tan E.S.M.; Roy C.S.D.; Sim P.; Leslie K.E.; Sim D.; Abul M.H.; Cody N.; Tay A.Y.; Woon E.; Sng S.; Mah J.; Robson J.; Shakweh E.; Wing V.C.; Mills H.; Li M.M.; Barrow T.R.; Balaji S.; Jordan H.E.M.; Phillips C.; Naveed H.; Hirani S.; Tai A.; Ratnakumaran R.; Sahathevan A.; Shafi A.M.A.; Seedat M.; Weaver R.; Batho A.; Punj R.; Selvachandran H.; Bhatt N.; Botchey S.; Khonat Z.; Brennan K.; Morrison C.J.; Devlin E.; Linton A.; Galloway E.; McGarvie S.; Ramsay N.; McRobbie H.D.; Whewell H.; Dean W.; Nelaj S.; Eragat M.; Mishra A.; Kane T.; Zuhair M.; Wells M.; Wilkinson D.; Woodcock N.; Sun E.; Aziz N.; Ghaffar M.K.A.; McLean K.A.; Glasbey J.C.; Borakati A.; Brooks T.M.; Chang H.M.; Choi S.M.; Goodson R.; Nielsen M.; Pronin S.; Salloum N.L.; Sewart E.; Vanniasegaram D.; Drake T.M.; Gillies M.A.; Harrison E.M.; Chapman S.J.; Khatri C.; Kong C.Y.; Bath M.F.; Kelly M.; Mitchell H.; Fitzgerald J.E.; Bhangu A.; Nepogodiev D

Citation:
British Journal of Anaesthesia; Jan 2019; vol. 122 (no. 1); p. 42-50

Abstract:
Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Method(s): This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy. Result(s): Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI. Conclusion(s): After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

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Blowing bubbles helps intubation (2017)

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Type of publication:
Journal article

Author(s):
*Howe, D.

Citation:
Indian Journal of Critical Care Medicine; Oct 2017; vol. 21 (no. 10); p. 710-711

Abstract:
Rocuronium is commonly used in preference to suxamethonium for rapid sequence induction in the Intensive Care Unit (ICU). We describe a patient who suffered significant neck trauma following a suicide attempt. On initial presentation to accident and emergency, he was an easy intubation with a Grade 1 view obtained at laryngoscopy. After surgery to repair his neck laceration, he was extubated and discharged from ICU. He later developed a severe aspiration pneumonia and required reintubation. After induction and paralysis with suxamethonium, the best view at laryngoscopy was a Grade 3 despite the use of different laryngoscopes. As the muscle paralysis wore off the patient began breathing. This produced bubbles in the back of the patient's pharynx which directed the clinician to the laryngeal inlet to allow successful intubation. In this case, the short duration of action of suxamethonium significantly aided intubation due to the return of spontaneous breathing by the patient.

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Can hospital early warning score systems be used to predict mortality and readmissions in patients with chronic obstructive pulmonary disease exacerbations requiring hospitalisation? (2014)

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Type of publication:
Conference abstract

Author(s):
*Crawford E.-J.T., *A lvarez E., *Moudgil H., *Naicker T.R., *Srinivasan K.S.

Citation:
American Journal of Respiratory and Critical Care Medicine, 2014, vol./is. 189/

Abstract:
Rationale: Predicting mortality in chronic obstructive pulmonary disease (COPD) can be complex as disease progression does not often follow a smooth downward trajectory. Identifying patients with COPD approaching the end of the ir life is important as it allows clinicians to initiate appropriately time d discussions centred around advance care planning and palliative care. High rates of early readmission to hospital (within 30 days of discharge) for patients with COPD is also of some national concern and to date, effective strategies to reduce this readmission rate have been limited. The use of early warning score (EWS) systems are now widespread in UK hospitals and are used primarily to alert nursing and medical staff to the severity of, or changes in, a patient's condition. This study aimed to understand whether the EWS systems could be used to predict 30 or 90 day mortality, or readmission rates in patients admitted to hospital with a COPD exacerbation. Met hods Data was collected from 73 consecutive patients admitted to hospital over a three month period (May to August, 2013) with an acute exacerbation of COPD. Collected data included early warning scores on admission, discharge and the peak EWS score. Data regarding in-hospital death, death within 30 and 90 days of admission date and readmission within 30 days of discharge was also collected. Results One patient (1.4%) died during their hospital admission. Four patients (5%) had died within 30 days of admission and 11 pa tients (15%) had died within 90 days of admission. 17 patients were re-admitted within 30 days of discharge (23%). There was no significant difference between median admission, peak and discharge early warning scores in those patients who had died within either 30 or 90 days of admission or who were readmitted within 30 days compared to the median values for the rest of th e group (see table). Conclusions According to the findings of this study, measurement of early warning scores cannot be used in clinical practice to p redict readmission rates, 30 or 90 day mortality in patients admitted to hospital with an acute exacerbation of COPD. (Table Presented).

The use of a remifentanil infusion and elective tracheostomy to avoid ventilation in a patient with tetanus (2014)

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Type of publication:
Journal article

Author(s):
*Redshaw C., *Slater R.

Citation:
Journal of the Intensive Care Society, April 2014, vol./is. 15/2(161-163), 1751-1437

Abstract:
Tetanus is very rare in developed countries but the mortality is still high in the elderly population despite access to intensive care medicine. Death can frequently occur from secondary complications due to the need to sedate, paralyse and ventilate patients in an effort to control spasms. We describe the case of a 77-year-old man with tetanus in whom we successfully controlled tetanic spasms with a remifentanil infusion where conventional treatment failed, thus preventing the need for mechanical ventilation. We also describe the use of an elective percutaneous tracheostomy which was performed for airway protection. This prevented him from developing pneumonia from aspirating the excess secretions caused by the autonomic features of tetanus.