The provision of central venous access, transfer of critically ill patients and advanced airway management.: Are advanced critical care practitioners safe and effective?

Advanced critical care practitioners are a new and growing component of the critical care multidisciplinary team in the United Kingdom. This audit considers the safety profile of advanced critical care practitioners in the provision of central venous catheterisation and transfer of ventilated critical care patients without direct supervision and supervised drug assisted intubation of critically ill patients. The audit showed that advanced critical care practitioners can perform central venous cannulation, transfer of critically ill ventilated patients and intubation with parity to published UK literature.

The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study.

INTRODUCTION: Compliance with the ventilator care bundle affects the rate of ventilator-associated pneumonia. It was not known, however, whether compliance with sepsis care bundles has an impact on outcome. The aims of the present study were to determine the rate of compliance with 6-hour and 24-hour sepsis bundles and to determine the impact of the compliance on hospital mortality in patients with severe sepsis or septic shock. METHODS: We conducted a prospective observational study on 101 consecutive adult patients with severe sepsis or septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service Trust Teaching hospitals in England. The main outcome measures were: the rate of compliance with 6-hour and 24-hour sepsis care bundles adapted from the Surviving Sepsis Campaign guidelines on patients' clinical care; and the difference in hospital mortality between the compliant and the non-compliant groups. RESULTS: The median age of the patients was 69 years (interquartile range 51 to 78), and 53% were male. The sources of infection were sought and confirmed in 87 of 101 patients. The chest was the most common source (50%), followed by the abdomen (22%). The rate of compliance with the 6-hour sepsis bundle was 52%. Compared with the compliant group, the non-compliant group had a more than twofold increase in hospital mortality (49% versus 23%, relative risk (RR) 2.12 (95% confidence interval (CI) 1.20 to 3.76), P = 0.01) despite similar age and severity of sepsis. Compliance with the 24-hour sepsis bundle was achieved in only 30% of eligible candidates (21/69). Hospital mortality was increased in the non-compliant group from 29% to 50%, with a 76% increase in risk for death, although the difference did not reach statistical significance (RR 1.76 (95% CI 0.84 to 3.64), P = 0.16). CONCLUSION: Non-compliance with the 6-hour sepsis bundle was associated with a more than twofold increase in hospital mortality. Non-compliance with the 24-hour sepsis bundle resulted in a 76% increase in risk for hospital death. All medical staff should practise these relatively simple, easy and cheap bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.

Safety and tolerability of nonbronchoscopic lavage in ARDS.

STUDY OBJECTIVE: This study compared the safety profiles of bronchoscopic lavage with nonbronchoscopic lavage in the investigation of patients with acute lung injury (ALI) or ARDS. DESIGN: Single-center, randomized, cross-over study. SETTING: General ICU in the United Kingdom. PARTICIPANTS: Fourteen patients with ALI or ARDS. INTERVENTIONS: Bronchoscopic BAL and nonbronchoscopic BAL 1 h apart. MEASUREMENTS AND RESULTS: Hemodynamic and ventilatory parameters were recorded during and for 1 h following each procedure. On average, bronchoscopic lavage took longer to perform than nonbronchoscopic lavage (7 min and 6 s vs 2 min and 28 s, p < 0.001). During the procedures, bronchoscopic lavage increased heart rate and systolic BP more than nonbronchoscopic lavage (23% vs 10% [p < 0.01] and 18% vs 7% [p < 0.01]). Three patients had ST-segment depression during bronchoscopic, and one patient had ST-segment depression during nonbronchoscopic lavage (p = 0.298). Bronchoscopic lavage reduced minute ventilation by 63 +/- 17.3%, while nonbronchoscopic lavage only reduced it by 36 +/- 21.9% (p < 0.001). Paco(2) rose more after bronchoscopic lavage than after nonbronchoscopic lavage. CONCLUSION: Nonbronchoscopic lavage is associated with less marked physiologic derangements than bronchoscopic lavage. Further studies are required to validate the hypothesis that nonbronchoscopic lavage may be safer in patients with unstable coronary heart disease or head injury/raised intracranial pressure who are at risk from unpredictable fluctuations in hemodynamic and ventilatory profiles.

Do different mattresses affect the quality of cardiopulmonary resuscitation?

OBJECTIVE: To determine the effect of different mattresses on cardiopulmonary resuscitation performance and establish whether emergency deflation of an inflatable mattress improves the quality of resuscitation. DESIGN AND SETTING: Randomised controlled cross-over trial performed in a general ICU PARTICIPANTS: Critical care staff from a general ICU. INTERVENTIONS: Cardiopulmonary resuscitation on a manikin on the floor or on a bed with a standard foam mattress and inflated and deflated pressure redistributing mattresses. Maximal compression force was measured at different bed heights. MEASUREMENTS AND RESULTS: Compression depth, duty cycle and rate and percentage correct expired air ventilation were recorded on a manikin. Compression depth was significantly lower on the foam (35.2 mm), inflated (37.2 mm) and deflated mattress (39.1 mm) than the floor (44.2 mm). There were no clinically important differences in duty cycle or compression rate. The quality of ventilation was poor on all surfaces. Maximal compression force declined as bed height increased. CONCLUSIONS: Resuscitation performance is adversely affected when performed on a bed (irrespective of mattress type) compared to the floor. There were no differences between the inflated and deflated mattresses, although the deflation process did not adversely affect performance. This study does not support the routine deflation of an inflated mattress during resuscitation and questions the potential benefits from using a backboard. The finding that bed height affects maximal compression forces, challenges the recommendation that cardiopulmonary resuscitation be performed with the bed at middle-thigh level and requires further investigation.

Do changes in pulse oximeter oxygen saturation predict equivalent changes in arterial oxygen saturation?

INTRODUCTION: This study investigates the relation between changes in pulse oximeter oxygen saturation (SpO2) and changes in arterial oxygen saturation (SaO2) in the critically ill, and the effects of acidosis and anaemia on precision of using pulse oximetry to predict SaO2. PATIENTS AND METHODS: Forty-one consecutive patients were recruited from a nine-bed general intensive care unit into a 2-month study. Patients with significant jaundice (bilirubin >40 micromol/l) or inadequate pulse oximetry tracing were excluded. RESULTS: A total of 1085 paired readings demonstrated only moderate correlation (r= 0.606; P < 0.01) between changes in SpO2 and those in SaO2, and the pulse oximeter tended to overestimate actual changes in SaO2. Anaemia increased the degree of positive bias whereas acidosis reduced it. However, the magnitude of these changes was small. CONCLUSION: Changes in SpO2 do not reliably predict equivalent changes in SaO2 in the critically ill. Neither anaemia nor acidosis alters the relation between SpO2 and SaO2 to any clinically important extent.