Norepinephrine pressor infusion withdrawal in a National Health Service hospice

2019 ◽  
pp. bmjspcare-2019-001895
Author(s):  
Elizabeth Woods ◽  
Lisa Baker ◽  
Jonathan Hindmarsh
Keyword(s):  
Blood Pressure ◽  
Critical Care ◽  
Intensive Care ◽  
National Health Service ◽  
Advanced Malignancy ◽  
Intensive Monitoring ◽  
Acute Hypotension ◽  
Profound Hypotension ◽  
Restore Blood Pressure ◽  
Emergency Measure

Norepinephrine (NE) is a peripheral vasoconstrictor used as an emergency measure to restore blood pressure secondary to acute hypotension. NE must be administered centrally as a continuous infusion and requires intensive monitoring. Consequently, its use is restricted to critical care environments. We discuss the withdrawal of NE in a hospice for a patient with advanced malignancy and profound hypotension from sepsis. The patient was admitted to intensive care but chose to stop active treatment and insisted on being discharged. Due to concerns about withdrawing NE in the community, he was transferred to a local hospice. We describe various challenges, including the administration and monitoring of NE outside of intensive care, the withdrawal process and concerns that profound hypotension might compromise subcutaneous medications absorption.

scholarly journals Report of the first AKI Round Table meeting: an initiative of the ESICM AKI Section

2019 ◽  
Vol 7 (1) ◽  
Author(s):  
M. Ostermann ◽  
A. Schneider ◽  
T. Rimmele ◽  
I. Bobek ◽  
M. van Dam ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Critical Care ◽  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Future Research ◽  
Knowledge Gaps ◽  
Blood Pressure Targets

Abstract Purpose Critical Care Nephrology is an emerging sub-specialty of Critical Care. Despite increasing awareness about the serious impact of acute kidney injury (AKI) and renal replacement therapy (RRT), important knowledge gaps persist. This report represents a summary of a 1-day meeting of the AKI section of the European Society of Intensive Care Medicine (ESICM) identifying priorities for future AKI research. Methods International Members of the AKI section of the ESICM were selected and allocated to one of three subgroups: “AKI diagnosis and evaluation”, “Medical management of AKI” and “Renal Replacement Therapy for AKI.” Using a modified Delphi methodology, each group identified knowledge gaps and developed potential proposals for future collaborative research. Results The following key research projects were developed: Systematic reviews: (a) epidemiology of AKI with stratification by patient cohorts and diagnostic criteria; (b) role of higher blood pressure targets in patients with hypertension admitted to the Intensive Care Unit, and (c) specific clearance characteristics of different modalities of continuous renal replacement therapy (CRRT). Observational studies: (a) epidemiology of critically ill patients according to AKI duration, and (b) current clinical practice of CRRT. Intervention studies:( a) Comparison of different blood pressure targets in critically ill patients with hypertension, and (b) comparison of clearance of solutes with various molecular weights between different CRRT modalities. Conclusion Consensus was reached on a future research agenda for the AKI section of the ESICM.

Framework for Biosignal Interpretation in Intensive Care and Anesthesia

1997 ◽  
Vol 36 (04/05) ◽  
pp. 340-344 ◽  
Author(s):  
I. Korhonen ◽  
M. van Gils ◽  
A. Kari ◽  
N. Saranummi
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Data Management ◽  
Clinical Evaluation ◽  
Patient Monitoring ◽  
Research Community ◽  
Clinical Routine ◽  
The Poor ◽  
Outcomes Of Care

Abstract:Improved monitoring improves outcomes of care. As critical care is “critical”, everything that can be done to detect and prevent complications as early as possible benefits the patients. In spite of major efforts by the research community to develop and apply sophisticated biosignal interpretation methods (BSI), the uptake of the results by industry has been poor. Consequently, the BSI methods used in clinical routine are fairly simple. This paper postulates that the main reason for the poor uptake is the insufficient bridging between the actors (i.e., clinicians, industry and research). This makes it difficult for the BSI developers to understand what can be implemented into commercial systems and what will be accepted by clinicians as routine tools. A framework is suggested that enables improved interaction and cooperation between the actors. This framework is based on the emerging commercial patient monitoring and data management platforms which can be shared and utilized by all concerned, from research to development and finally to clinical evaluation.

The Association of Pediatric Critical Care Medicine Training Programs with Research Publication Productivity and Employment Outcomes of Their Graduates

2020 ◽  
Author(s):  
Sonali Basu ◽  
Robin Horak ◽  
Murray M. Pollack
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Medical School ◽  
Training Programs ◽  
Fellowship Training ◽  
Publication Productivity ◽  
Research Publication ◽  
Pediatric Critical Care ◽  
Publication Success ◽  
Fellowship Programs

AbstractOur objective was to associate characteristics of pediatric critical care medicine (PCCM) fellowship training programs with career outcomes of PCCM physicians, including research publication productivity and employment characteristics. This is a descriptive study using publicly available data from 2557 PCCM physicians from the National Provider Index registry. We analyzed data on a systematic sample of 690 PCCM physicians representing 62 fellowship programs. There was substantial diversity in the characteristics of fellowship training programs in terms of fellowship size, intensive care unit (ICU) bed numbers, age of program, location, research rank of affiliated medical school, and academic metrics based on publication productivity of their graduates standardized over time. The clinical and academic attributes of fellowship training programs were associated with publication success and characteristics of their graduates' employment hospital. Programs with greater publication rate per graduate had more ICU beds and were associated with higher ranked medical schools. At the physician level, training program attributes including larger size, older program, and higher academic metrics were associated with graduates with greater publication productivity. There were varied characteristics of current employment hospitals, with graduates from larger, more academic fellowship training programs more likely to work in larger pediatric intensive care units (24 [interquartile range, IQR: 16–35] vs. 19 [IQR: 12–24] beds; p < 0.001), freestanding children's hospitals (52.6 vs. 26.3%; p < 0.001), hospitals with fellowship programs (57.3 vs. 40.3%; p = 0.01), and higher affiliated medical school research ranks (35.5 [IQR: 14–72] vs. 62 [IQR: 32, unranked]; p < 0.001). Large programs with higher academic metrics train physicians with greater publication success (H index 3 [IQR: 1–7] vs. 2 [IQR: 0–6]; p < 0.001) and greater likelihood of working in large academic centers. These associations may guide prospective trainees as they choose training programs that may foster their career values.

scholarly journals Paediatric admissions to a district general hospital adult intensive care unit over a six year period: A single centre retrospective case series, with review of practitioner confidence and competence in paediatric critical care

2021 ◽  
pp. 175114372110121
Author(s):  
Stephen A Spencer ◽  
Joanna S Gumley ◽  
Marcin Pachucki
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Intensive Care Units ◽  
Case Series ◽  
Critically Ill Children ◽  
Single Centre ◽  
Retrospective Case ◽  
Retrospective Case Series ◽  
Paediatric Critical Care ◽  
Doctors And Nurses

Background Critically ill children presenting to district general hospitals (DGH) are admitted to adult intensive care units (AICUs) for stabilisation prior to transfer to paediatric intensive care units (PICUs). Current training in PICU for adult intensive care physicians is only three months. This single centre retrospective case series examines the case mix of children presenting to a DGH AICU and a multidisciplinary survey assesses confidence and previous experience, highlighting continued training needs for DGH AICU staff. Methods all paediatric admissions to AICU and paediatric retrievals were reviewed over a 6-year period (2014-2019). Cases were identified from the Electronic Patient Record (EPR) and from data provided by the regional paediatric retrieval service. A questionnaire survey was sent to AICU doctors and nurses to assess confidence and competence in paediatric critical care. Results Between 2014-2019, 284 children were managed by AICU. In total 35% of cases were <1 y, 48% of cases were <2 y and 64% of cases were <5 y, and 166/284 (58%) children were retrieved. Retrieval reduced with increasing age (OR 0.49 [0.40-0.60], p < 0.0001). The survey had an 82% response rate, and highlighted that only 13% of AICU nurses and 50% of doctors had received prior PICU training. Conclusion At least one critically unwell child presents to the AICU each week. Assessment, stabilisation and management of critically unwell children are vital skills for DGH AICU staff, but confidence and competence are lacking. Formalised strategies are required to develop and maintain paediatric competencies for AICU doctors and nurses.

scholarly journals A Timely Call to Arms: COVID-19, the Circadian Clock, and Critical Care

2021 ◽  
Vol 36 (1) ◽  
pp. 55-70
Author(s):  
Jeffrey Haspel ◽  
Minjee Kim ◽  
Phyllis Zee ◽  
Tanja Schwarzmeier ◽  
Sara Montagnese ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Human Physiology ◽  
Critical Care ◽  
Intensive Care ◽  
Severe Acute Respiratory Syndrome ◽  
Circadian Clock ◽  
Clinical Course ◽  
Disease Expression ◽  
Severe Manifestation ◽  
Novel Coronavirus

We currently find ourselves in the midst of a global coronavirus disease 2019 (COVID-19) pandemic, caused by the highly infectious novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Here, we discuss aspects of SARS-CoV-2 biology and pathology and how these might interact with the circadian clock of the host. We further focus on the severe manifestation of the illness, leading to hospitalization in an intensive care unit. The most common severe complications of COVID-19 relate to clock-regulated human physiology. We speculate on how the pandemic might be used to gain insights on the circadian clock but, more importantly, on how knowledge of the circadian clock might be used to mitigate the disease expression and the clinical course of COVID-19.

scholarly journals The Association Between Arterial Oxygen Level and Outcome in Neurocritically Ill Patients is not Affected by Blood Pressure

2021 ◽  
Author(s):  
Jaana Humaloja ◽  
Markus B. Skrifvars ◽  
Rahul Raj ◽  
Erika Wilkman ◽  
Pirkka T. Pekkarinen ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Intensive Care ◽  
Brain Injury ◽  
Hemodynamic Instability ◽  
Arterial Oxygen ◽  
Admission Diagnosis ◽  
Secondary Brain Injury ◽  
Multivariable Logistic Regression Model ◽  
Mechanically Ventilated ◽  
The Relationship

Abstract Background In neurocritically ill patients, one early mechanism behind secondary brain injury is low systemic blood pressure resulting in inadequate cerebral perfusion and consequent hypoxia. Intuitively, higher partial pressures of arterial oxygen (PaO2) could be protective in case of inadequate cerebral circulation related to hemodynamic instability. Study purpose We examined whether the association between PaO2 and mortality is different in patients with low compared to normal and high mean arterial pressure (MAP) in patients after various types of brain injury. Methods We screened the Finnish Intensive Care Consortium database for mechanically ventilated adult (≥ 18) brain injury patients treated in several tertiary intensive care units (ICUs) between 2003 and 2013. Admission diagnoses included traumatic brain injury, cardiac arrest, subarachnoid and intracranial hemorrhage, and acute ischemic stroke. The primary exposures of interest were PaO2 (recorded in connection with the lowest measured PaO2/fraction of inspired oxygen ratio) and the lowest MAP, recorded during the first 24 h in the ICU. PaO2 was grouped as follows: hypoxemia (< 8.2 kPa, the lowest 10th percentile), normoxemia (8.2–18.3 kPa), and hyperoxemia (> 18.3 kPa, the highest 10th percentile), and MAP was divided into equally sized tertiles (< 60, 60–68, and > 68 mmHg). The primary outcome was 1-year mortality. We tested the association between hyperoxemia, MAP, and mortality with a multivariable logistic regression model, including the PaO2, MAP, and interaction of PaO2*MAP, adjusting for age, admission diagnosis, premorbid physical performance, vasoactive use, intracranial pressure monitoring use, and disease severity. The relationship between predicted 1-year mortality and PaO2 was visualized with locally weighted scatterplot smoothing curves (Loess) for different MAP levels. Results From a total of 8290 patients, 3912 (47%) were dead at 1 year. PaO2 was not an independent predictor of mortality: the odds ratio (OR) for hyperoxemia was 1.16 (95% CI 0.85–1.59) and for hypoxemia 1.24 (95% CI 0.96–1.61) compared to normoxemia. Higher MAP predicted lower mortality: OR for MAP 60–68 mmHg was 0.73 (95% CI 0.64–0.84) and for MAP > 68 mmHg 0.80 (95% CI 0.69–0.92) compared to MAP < 60 mmHg. The interaction term PaO2*MAP was nonsignificant. In Loess visualization, the relationship between PaO2 and predicted mortality appeared similar in all MAP tertiles. Conclusions During the first 24 h of ICU treatment in mechanically ventilated brain injured patients, the association between PaO2 and mortality was not different in patients with low compared to normal MAP.

scholarly journals 379 The Critical Care Experience of Irish Surgical Non-Consultant Hospital Doctors, Are We Equipped to Assist During the Covid-19 Outbreak and Beyond?

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
E Burke ◽  
P Balfe
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Healthcare Systems ◽  
Care Environment ◽  
Care Experience ◽  
Electronic Survey ◽  
Surgical Trainees ◽  
Hospital Doctors ◽  
Basic Course ◽  
Further Development

Abstract Introduction The ongoing COVID-19 pandemic has presented unforeseen threats and stresses to healthcare systems around the world, most notably in the ability to provide critical care. Aim To assess surgical NCHD experience in providing critical care and working in an intensive care environment. Method An electronic survey was distributed amongst surgical trainees and then amongst individual surgical departments. Ten questions were included in the survey assessing the NCHD’s experience with aspects of critical care. Results 39 respondents including 16 specialist registrars, 3 senior registrars, 11 registrars and 9 senior house officers. 18% of respondents had previous experience in anaesthetics or intensive care. 23% self-reported being competent in performing endotracheal intubation. 15% self-reported being competent in the use of CPAP and BiPaP, 5% did not know what these were. 20% self-reported being competent in the use of AIRVO. 15% self-reported being competent in placing central and arterial lines. 15% self-reported being competent in starting and adjusting inotropes/vasopressors. 49% reported completing a CCRISP or BASIC course. 85% felt that a rotation in anaesthesia should be a routine part of surgical training. Conclusions Whilst there is critical care experience amongst the surgical NCHD cohort there remains room for further development.

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