Queen’s University Belfast-led study examines potential of new technology that could save lives in ICUs

A potentially revolutionary new technology – that could saves thousands of lives in Intensive Care Units around the world – is being trialled in a UK study co-led by Queen’s University Belfast.

Covering 1,120 critically ill patients in 40 different sites in Britain and Northern Ireland over five years, the research project will test a new strategy designed to minimise damage to the lungs caused by mechanical ventilation – commonly referred to as ‘ventilators’. The study will be one of the largest clinical trials in the world, to date, involving patients with respiratory failure.

The National Institute for Health Research (NIHR) has funded the £2.1 million research which will be jointly led by Queen’s and Belfast Health and Social Services Trust.

For more details see the report on Queen’s University website link

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Identify sepsis in patients by using early warning scores, doctors are urged

General practitioners and hospital doctors should all use an early warning score system when they suspect that a patient may have sepsis to help improve the recognition of cases, a report recommends.1

Nearly half (45%) of patients with sepsis admitted to hospital with no other obvious problem either died or were left with a disability, an audit of cases in England, Wales, and Northern Ireland has found.

A third (34%; 184) of the 544 hospitals reviewed had no formal sepsis protocol to identify and manage patients with sepsis, and this needs to be rectified, said a report into sepsis by the National Confidential Enquiry into Patient Outcome and Death.1

The inquiry reviewed the care of all patients who were seen by critical care teams in the community or admitted to hospital with a diagnosis of sepsis during two weeks in May 2014. Some 3363 patients were identified overall, 884 cases were selected for inclusion, and the case notes of 551 were examined. For the first time the inquiry also looked at events in general practice: 129 patients were seen by their GP, and the notes of 54 were reviewed.

An early warning scores system was used in none of the cases seen by GPs and in just 27% (128/479) of cases seen in secondary care. Of the 129 cases seen by a GP, only 34 patients (26%) had their temperature taken and 40 (31%) had their heart rate taken. In hospitals, 41% (152/369) of patients had a complete set of vital signs recorded.

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6237  (Published 24 November 2015) Cite this as: BMJ 2015;351:h6237

Trends in the Adult Inpatient Survey 2005-2014

Overall over ten years, results indicate that patients’ experiences of care have generally been good. However, most areas we ask patients about have seen little meaningful change or improvement. Where substantial improvements are evident, these seem to be associated with the introduction of national policies and initiatives, for example in cleanliness and mixed sex accommodation. Although most areas of patient experience have remained static or showed improvement there have been areas of deterioration, for example in waiting times.

The statistical release provides the main findings together with contextual policy information and information on the survey methodology.
http://www.cqc.org.uk/content/trends-adult-inpatient-survey-2005-2014

Doctors can withdraw feeding from patient in minimally conscious state, judge rules

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6292 (Published 20 November 2015)

A judge has ruled for the first time in a UK court that a patient in a minimally conscious state should have artificial feeding withdrawn and be allowed to die.

Mr Justice Hayden concluded at the Court of Protection in London that it would be “disrespectful” to the 68 year old woman, “N,” in the end stages of multiple sclerosis “to preserve her further in a manner I think she would regard as grotesque.”

In 1993, in the case of the Hillsborough football ground disaster survivor Tony Bland, the House of Lords, then the highest court in the United Kingdom, ruled that doctors need not keep someone alive if life was conferring no benefit. In a series of cases since then courts have authorised the withdrawal of artificial nutrition and hydration from patients in a persistent vegetative state.

In 2011 the Court of Protection considered for the first time the case of a patient in a minimally conscious state, a level just above persistent vegetative state. But after hearing evidence from the patient’s family about what her wishes would have been, Mr Justice Baker ruled that she had “some positive experiences” and that the presumption favouring the preservation of life should prevail.1

In the latest case, evidence from N’s daughter, son, and former husband about the sort of woman she was and what she would have wanted persuaded the official solicitor, who represented her and initially opposed the family’s application to discontinue feeding, to change his mind.

N, who lives in a care home in northwest England, was given a diagnosis of multiple sclerosis 23 years ago. Her condition is unchanged since 2008 and she would be deemed to be in persistent vegetative state but for her ability to fix and track objects in her line of vision.

After hearing the family’s evidence the judge said that he was “left with little doubt that Mrs N would have been appalled to contemplate the early pain, increasing dependency, and remorseless degeneration that has now characterised her life for so long” and would have wished to discontinue treatment “some considerable time ago.”

He added, “Ultimately, I have concluded that her wishes, so thoughtfully presented by her family, coupled with the intrusive nature of the treatment and its minimal potential to achieve any medical objective, rebut any presumption of continuing to promote life.”

Lighting, sleep and circadian rhythm: An intervention study in the intensive care unit

Engwall, Fridh, Johansson, Bergbom & Lindahl
Journal of Intensive and Critical Care Nursing
December 2015 Volume 31, Issue 6, Pages 325–335
Patients in an intensive care unit (ICU) may risk disruption of their circadian rhythm. In an intervention research project a cycled lighting system was set up in an ICU room to support patients’ circadian rhythm. Part I aimed to compare experiences of the lighting environment in two rooms with different lighting environments by lighting experiences questionnaire. The results indicated differences in advantage for the patients in the intervention room (n = 48), in perception of daytime brightness (p = 0.004). In nighttime, greater lighting variation (p = 0.005) was found in the ordinary room (n = 52). Part II aimed to describe experiences of lighting in the room equipped with the cycled lighting environment. Patients (n = 19) were interviewed and the results were presented in categories: “A dynamic lighting environment”, “Impact of lighting on patients’ sleep”, “The impact of lighting/lights on circadian rhythm” and “The lighting calms”. Most had experiences from sleep disorders and half had nightmares/sights and circadian rhythm disruption. Nearly all were pleased with the cycled lighting environment, which together with daylight supported their circadian rhythm. In night’s actual lighting levels helped patients and staff to connect which engendered feelings of calm.

Antibiotic resistance: World on cusp of ‘post-antibiotic era’

The world is on the cusp of a “post-antibiotic era”, scientists have warned after finding bacteria resistant to drugs used when all other treatments have failed.
They identified bacteria able to shrug off the drug of last resort – colistin – in patients and livestock in China.
They said that resistance would spread around the world and raised the spectre of untreatable infections.
It is likely resistance emerged after colistin was overused in farm animals.
Bacteria becoming completely resistant to treatment – also known as the antibiotic apocalypse – could plunge medicine back into the dark ages.

http://www.bbc.co.uk/news/health-34857015

Automatic versus manual changeovers of norepinephrine infusion pumps in critically ill adults: a prospective controlled study

Critically ill; Shock; Changeover; Catecholamines; Norepinephrine; Smart infusion pumps

 

Background
annals of intensive careNorepinephrine is a key drug for treating shock but has a short half-life that requires continuous intravenous administration to maintain the constant plasma concentration needed to obtain a stable blood pressure. The small volume of the syringes used in power infusion pumps requires frequent changeovers, which can lead to norepinephrine flow interruptions responsible for hemodynamic instability. Changeovers from the nearly empty to the full syringe can be performed manually using the quick change technique (QC) or automatically using smart infusion pumps (SIP) that link two syringes. The purpose of our study was to evaluate the hypothesis that, compared to QC, SIP for norepinephrine changeovers was associated with less hemodynamic instability.

Methods
After information of the patient or next of kin, patients receiving norepinephrine for shock were allocated to QC or SIP changeovers. QC changeovers were performed by a nurse, who started a new loaded pump when the previous syringe was nearly empty. SIP changeovers were managed automatically by SIP workstations. The primary outcome was the proportion of changeovers followed by a ≥20 % drop in mean arterial pressure (MAP).

Results
411 changeovers were performed, 193 in the 18 patients allocated to QC and 218 in the 32 patients allocated to SIP. Baseline patient characteristics were similar in both groups. The proportion of changeovers followed by an MAP drop ≥20 % was 12.4 % (24/193) with QC and 5.5 % (12/218) with SIP (P = 0.01). By multivariate analysis, two factors were independently associated with a significantly decreased risk of ≥20 % MAP drops during changeovers, namely, SIP (odds ratio, 0.47; 95 % confidence interval, 0.22–0.98) and norepinephrine dosage >0.5 μg/kg/min (odds ratio, 0.39; 95 % confidence interval, 0.19–0.81).

Conclusions
The risk of MAP drops ≥20 % during changeovers can be significantly diminished using SIPs instead of the QC method.

http://www.annalsofintensivecare.com/content/5/1/40