Driving resumption after critical illness:A survey and framework analysis of patient experience and process.

Background: Adverse sequelae are common in survivors of critical illness. Physical, psychological and cognitive impairments can affect quality of life for years after the original insult. Driving is an advanced task reliant on complex physical and cognitive functioning. Driving represents a positive recovery milestone. Little is currently known about the driving habits of critical care survivors. The aim of this study was to explore the driving practices of individuals after critical illness. Methods: A purpose-designed questionnaire was distributed to driving licence holders attending critical care recovery clinic. Results: A response rate of 90% was achieved. 43 respondents declared their intention to resume driving. Two respondents had surrendered their licence on medical grounds. 68% had resumed driving by 3 months, 77% by 6 months, and 84% by 1 year. The median interval (range) between critical care discharge and resumption of driving was 8 weeks (1-52 weeks). Psychological, physical and cognitive barriers were cited by respondents as barriers to driving resumption. Eight themes regarding driving resumption were identified from the framework analysis under three core domains and included: psychological/cognitive impact on ability to drive (Emotional readiness and anxiety; Confidence; Intrinsic motivation; Concentration), physical ability to drive (Weakness and fatigue; Physical recovery), and supportive care and information needs to resume driving (Information/advice; Timescales). Conclusion: This study demonstrates that resumption of driving following critical illness is substantially delayed. Qualitative analysis identified potentially modifiable barriers to driving resumption.

Recovery, rehabilitation and follow-up services following critical illness: an updated UK national cross-sectional survey and progress report.

OBJECTIVE: To comprehensively update and survey the current provision of recovery, rehabilitation and follow-up services for adult critical care patients across the UK. DESIGN: Cross-sectional, self-administered, predominantly closed-question, electronic, online survey. SETTING: Institutions providing adult critical care services identified from national databases. PARTICIPANTS: Multiprofessional critical care clinicians delivering services at each site. RESULTS: Responses from 176 UK hospital sites were included (176/242, 72.7%). Inpatient recovery and follow-up services were present at 127/176 (72.2%) sites, adopting multiple formats of delivery and primarily delivered by nurses (n=115/127, 90.6%). Outpatient services ran at 130 sites (73.9%), predominantly as outpatient clinics. Most services (n=108/130, 83.1%) were co-delivered by two or more healthcare professionals, typically nurse/intensive care unit (ICU) physician (n=29/130, 22.3%) or nurse/ICU physician/physiotherapist (n=19/130, 14.6%) teams. Clinical psychology was most frequently lacking from inpatient or outpatient services. Lack of funding was consistently the primary barrier to service provision, with other barriers including logistical and service prioritisation factors indicating that infrastructure and profile for services remain inadequate. Posthospital discharge physical rehabilitation programmes were relatively few (n=31/176, 17.6%), but peer support services were available in nearly half of responding institutions (n=85/176, 48.3%). The effects of the COVID-19 pandemic resulted in either increasing, decreasing or reformatting service provision. Future plans for long-term service transformation focus on expansion of current, and establishment of new, outpatient services. CONCLUSION: Overall, these data demonstrate a proliferation of recovery, follow-up and rehabilitation services for critically ill adults in the past decade across the UK, although service gaps remain suggesting further work is required for guideline implementation. Findings can be used to enhance survivorship for critically ill adults, inform policymakers and commissioners, and provide comparative data and experiential insights for clinicians designing models of care in international healthcare jurisdictions.

The Angel catheter for the prevention of pulmonary embolism: combining an IVC filter and a triple-lumen central venous catheter.

INTRODUCTION: Pulmonary embolism is common in critical care patients and carries significant morbidity and mortality. Concurrent risk of severe bleeding in this population may prohibit anticoagulation. Areas covered: The Angel Catheter device is a central venous catheter combined with an inferior vena cava filter inserted at the bedside for pulmonary embolism prevention. Our review examines the role of this device, safety, efficacy and the limitations it presents. Expert commentary: We conclude the Angel catheter should be considered in critical care patients with significant risk of pulmonary embolus as bridging therapy until anticoagulation can be safely resumed.

Bedside implantation of a new temporary vena cava inferior filter - Safety and efficacy results of the European ANGEL-Registry.

PURPOSE: Pulmonary embolism (PE) is a frequently occurring complication in critically ill patients. Simultaneous occurrence of PE and life-threatening bleeding, may render medical anticoagulation impossible. For these patients, inferior vena cava filters (IVCF) present a valuable therapeutic alternative. The Angel® catheter is a novel IVCF that provides temporary protection from PE and is implanted at bedside. The primary objective of the European Angel® catheter registry is to evaluate the safety and efficacy of this IVCF. MATERIAL AND METHODS: The European Angel® catheter registry is an observational, multi-centre registry. Patients from four countries and eight sites that have undergone Angel® catheter implantation between March 2013 and February 2017 were enrolled. RESULTS: A total of 114 critically ill patients were included. The main indication for implantation was a high-risk for PE in combination with contraindications for anticoagulation (69.3%). One clinically non-significant PE (0.9%) occurred in a patient with an indwelling Angel® catheter. No cases of catheter associated serious complications were observed. CONCLUSION: Data shows that the Angel® catheter is a safe and effective approach to overcome the acute phase of critically ill patients with a high risk for the development of PE or an established PE, when an anticoagulation therapy is contraindicated.

A practical approach to Events Medicine provision.

In the past three decades, mass casualty incidents have occurred worldwide at multiple sporting events and other mass gatherings. Organisational safety and healthcare provision can consequently be scrutinised post-event. Within the UK, such incidents in the 1980s provided incentives to improve medical services and subsequent high profile UK-based international sporting events (London Olympics and Paralympics 2012, Glasgow Commonwealth Games 2014, Rugby World Cup 2015) added a further catalyst for developing services. Furthermore in the aftermath of the abandoned France versus Germany association football match at the Stade de France (Paris Terrorist Attacks, November 2015) and the 2016 UK report from HM Coroner on the Hillsborough Inquest, medical cover at sporting events is being further reviewed. Doctors providing spectator cover therefore need to have an awareness of their likely roles at sporting venues. Formal guidance exists in many countries for the provision of such cover but remains generic even though Events Medicine is increasingly recognised as a necessary service. The current evidence base is limited with best practice examples often anecdotally cited by acute care specialists (eg, emergency medicine) who provide cover. This article is therefore intended to present an overview for doctors of the knowledge and skills required to treat ill and injured spectators and enable them to adequately risk-assess venues in cooperation with other health and safety providers, including preparation for a major incident. It also gives guidance on how activity can be adequately assessed and how doctors can have management roles in Events Medicine.

Obstetric early warning systems to prevent bad outcome.

PURPOSE OF REVIEW: Early warning scores, early warning systems and rapid response systems, were established in 1999. In the UK, a National Early Warning Score was launched in 2013 and is now used throughout the National Health Service. In 2007, a firm recommendation was made by the maternal confidential death enquiry that maternity units should incorporate a modified early obstetric warning score chart into clinical practice. Although there was enthusiastic uptake of this recommendation, local recording systems vary throughout the country and there is now a need to revisit revise and standardize an obstetric early warning system (ObsEWS). RECENT PROJECT: The intercollegiate Maternal Critical Care group of the Obstetric Anaesthetists' Association have produced an ObsEWS in line with the aggregate UK National Early Warning Score. Six physiological parameters are incorporated: respiratory rate, oxygen saturations, temperature, systolic blood pressure, diastolic blood pressure, and pulse rate. However, robust physiological thresholds for the measured parameters are currently lacking but required for a more sensitive and specific ObsEWS. SUMMARY: A greater focus and study on the management of maternal morbidity (in addition to mortality data) and the development of better systems within and across the multidisciplinary team to detect early deterioration should improve management of serious illness in obstetrics. It is imperative that we undertake robust ObsEWS and data collection, including electronic systems with research and evidence-based recommendations to underpin this system. This should improve patient safety and result in more efficient, cost-effective management of sicker patients in our complex modern healthcare systems.

A new device for the prevention of pulmonary embolism in critically ill patients: Results of the European Angel Catheter Registry.

BACKGROUND: Pulmonary embolism (PE) is a potentially life-threatening complication of critical illness. In trauma and neurosurgical patients with contraindications to anticoagulation, inferior vena cava (IVC) filters have been used to prevent PE, but their associated long-term complication rates and difficulties associated with filter removal have limited their use. The Angel catheter is a temporary device, which combined an IVC filter with a triple-lumen central venous catheter (IVC filter-catheter) and is intended for bedside placement and removal when no longer indicated. METHODS: This study presents data from a European Registry of 60 critically ill patients in whom the IVC filter-catheter was used to prevent PE. The patients were all at high risk of PE development or recurrence and had contraindications to anticoagulation. The primary end points of this study were to evaluate the safety (in particular, the presence of infectious or thrombotic events) and effectiveness (the numbers of PEs and averted PEs) of the IVC filter-catheter. RESULTS: The main diagnosis before catheter insertion was major trauma in 33 patients (55%), intracerebral hemorrhage or stroke in 9 (15%), a venous thromboembolic event in 9 (15%), and active bleeding in 6 (10%). The IVC filter-catheter was placed as prophylaxis in 51 patients (85%) and as treatment in the 9 patients (15%) with venous thromboembolic event. The devices were inserted at the bedside without fluoroscopic guidance in 54 patients (90%) and within a median of 4 days after hospital admission. They were left in place for a mean of 6 days (4-8 days). One patient developed a PE, without hemodynamic compromise; two PEs were averted. No serious adverse events were reported. CONCLUSION: Early bedside placement of an IVC filter-catheter is possible, and our results suggest that this is a safe, effective alternative to short-term PE prophylaxis for high-risk patients with contraindications to anticoagulation. LEVEL OF EVIDENCE: Therapeutic study, level V.

Autopsy and critical care.

An autopsy is a medical procedure consisting of the thorough examination of the body and internal organs after death, to evaluate disease or injury and to determine the cause and manner of a person's death. In the intensive care setting, autopsies are usually performed to determine the cause of death or further medical knowledge. Early evidence that showed an alarmingly high rate of medical misdiagnosis found at autopsy is being called into question; the role of the procedure itself is being scrutinised. Furthermore, there has been a marked decline in the number of autopsies being performed both in the UK and across Europe. We examine the role of autopsies in modern health care for critically ill patients.

Effective management of severe traumatic brain injury in a district hospital.

The authors investigated how effectively adults with severe traumatic brain injury (TBI) can be managed in a district general hospital intensive care unit offering intracranial pressure monitoring (ICPM) receiving advice from a neurosurgical unit. A single-centre case series with retrospective review of prospectively collected information was undertaken of 44 consecutive patients presenting over seven years from January 2003 to January 2010 with severe traumatic brain injury to a single district general hospital intensive care unit serving a population of 500,000 adults. A prospectively entered clinical database was used to obtain information including patient demographics, Glasgow Coma Score (GCS) on admission, ICPM insertion, ICPM-related complications, inpatient mortality and neurosurgical advice. Case notes were used to ratify information and obtain neurorehabilitation clinic functional outcome scores. Forty-four patients were identified (40 male, age range 16-77 years). Mortality in intensive care was 30%. Twenty-eight patients received frontal twist drill ICPM following neurosurgical advice. ICPM had 2 (7%) device malfunctions but no other complications. Twelve additional patients were transferred to tertiary centres. Patients (23 of 31) who survived ICU stay (74%) were referred to neurorehabilitation. Mean clinic follow-up was 14 months. All patients had a Glasgow Outcome Score (GOS) of 3 or 4 at initial clinic assessment. Twenty-two improved to GOS to 4 or 5 at clinic discharge. One patient died prior to clinic discharge. Carefully selected patients with severe TBI can be managed safely and effectively in a district general hospital offering ICPM insertion if transfer to a neurosurgical centre is not possible. Neurosurgical advice regarding patient selection and on-going management is fundamental to provide a good service. Protocol driven therapies provide a useful systematic approach to doctors who do not deal with severe TBI on a routine basis.

Toward intelligent hemodynamic monitoring: a functional approach.

Technology is now available to allow a complete haemodynamic analysis; however this is only used in a small proportion of patients and seems to occur when the medical staff have the time and inclination. As a result of this, significant delays occur between an event, its diagnosis and therefore, any treatment required. We can speculate that we should be able to collect enough real time information to make a complete, real time, haemodynamic diagnosis in all critically ill patients. This article advocates for "intelligent haemodynamic monitoring". Following the steps of a functional analysis, we answered six basic questions. (1) What is the actual best theoretical model for describing haemodynamic disorders? (2) What are the needed and necessary input/output data for describing this model? (3) What are the specific quality criteria and tolerances for collecting each input variable? (4) Based on these criteria, what are the validated available technologies for monitoring each input variable, continuously, real time, and if possible non-invasively? (5) How can we integrate all the needed reliably monitored input variables into the same system for continuously describing the global haemodynamic model? (6) Is it possible to implement this global model into intelligent programs that are able to differentiate clinically relevant changes as opposed to artificial changes and to display intelligent messages and/or diagnoses?

Sexual dysfunction in intensive care survivors.

Normal sexual function is an important component of a patient's overall health status. Sexual dysfunction has been described in a variety of patient populations including survivors of critical illness. This review gives an overview of the issues pertaining to sexual dysfunction in patients who have experienced intensive care unit treatment.

Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis.

BACKGROUND: Immobility is associated with complications involving many body systems. OBJECTIVE: To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients. METHODS: Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses. RESULTS: A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality. CONCLUSIONS: Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.

Excellent anaesthesia needs patient preparation and postoperative support to influence outcome.

PURPOSE OF REVIEW: Studies over many years have demonstrated that preoptimization and attention to appropriate perioperative care is associated with a substantial decrease in surgical mortality. This review discusses ways in which patient preparation and perioperative support can minimize surgical mortality and morbidity. RECENT FINDINGS: Scoring systems continue to be developed in order to classify categories of surgical risk. Objective physiologically based assessments can also identify high-risk groups of patients. Debate continues over the indications for specific interventions such as beta-blockade or statin therapy. There is continuing interest in perioperative optimization of oxygen delivery. A multimodality approach paying attention to a range of possible interventions appears to be beneficial. Audit, training, experience and a sufficient volume of procedures are all factors associated with surgical mortality. SUMMARY: The provision of a high-quality service throughout the perioperative period is vital for a successful outcome. Patients need to be assessed well before major elective surgery to determine if they fall into a high-risk category. Some patients may benefit from a change in management. Postoperatively, critical-care support should be available backed by level 1 (enhanced ward) care with input from outreach or medical emergency teams 24 hours per day, seven days a week.

A self-report-based study of the incidence and associations of sexual dysfunction in survivors of intensive care treatment.

OBJECTIVES: To determine the incidence and associations of sexual dysfunction in survivors of intensive care unit treatment in their first year after hospital discharge using a self-report measure. DESIGN: A prospective observational study. SETTING: ICU Follow-up Clinic, The Royal Berkshire Hospital, Reading. SUBJECTS: One hundred and twenty-seven patients aged 18 years and over who spent 3 days or more in the intensive care unit. MAIN OUTCOME MEASURES: Demographic data; reported incidence of sexual dysfunction and post-traumatic stress disorder symptomatology; association between reported sexual dysfunction and age, gender, post-traumatic stress disorder symptomatology and length of intensive care unit stay; patient and partner satisfaction with current sex life. RESULTS: Fifty-two patients (43.6%) reported symptoms of sexual dysfunction. There was a significant association between sexual dysfunction and post-traumatic stress disorder symptomatology (p = 0.019). There was no association between reported sexual dysfunction and gender (p = 0.33), age (p = 0.8) or intensive care unit length of stay (p = 0.41). Forty-five per cent of patients and 40% of partners were not satisfied with their current sex life. No other medical practitioner had sought symptoms of sexual dysfunction during the study period. CONCLUSIONS: Symptoms of sexual dysfunction are common in patients recovering from critical illness and appear to be significantly associated with the presence of post-traumatic stress disorder symptomatology. The intensive care unit follow-up clinic is a suitable forum for the screening and referral of patients with sexual dysfunction.

Management of the critically ill patient with severe acute pancreatitis.

OBJECTIVE: Acute pancreatitis represents a spectrum of disease ranging from a mild, self-limited course requiring only brief hospitalization to a rapidly progressive, fulminant illness resulting in the multiple organ dysfunction syndrome (MODS), with or without accompanying sepsis. The goal of this consensus statement is to provide recommendations regarding the management of the critically ill patient with severe acute pancreatitis (SAP). DATA SOURCES AND METHODS: An international consensus conference was held in April 2004 to develop recommendations for the management of the critically ill patient with SAP. Evidence-based recommendations were developed by a jury of ten persons representing surgery, internal medicine, and critical care after conferring with experts and reviewing the pertinent literature to address specific questions concerning the management of patients with severe acute pancreatitis. DATA SYNTHESIS: There were a total of 23 recommendations developed to provide guidance to critical care clinicians caring for the patient with SAP. Topics addressed were as follows. 1) When should the patient admitted with acute pancreatitis be monitored in an ICU or stepdown unit? 2) Should patients with severe acute pancreatitis receive prophylactic antibiotics? 3) What is the optimal mode and timing of nutritional support for the patient with SAP? 4) What are the indications for surgery in acute pancreatitis, what is the optimal timing for intervention, and what are the roles for less invasive approaches including percutaneous drainage and laparoscopy? 5) Under what circumstances should patients with gallstone pancreatitis undergo interventions for clearance of the bile duct? 6) Is there a role for therapy targeting the inflammatory response in the patient with SAP? Some of the recommendations included a recommendation against the routine use of prophylactic systemic antibacterial or antifungal agents in patients with necrotizing pancreatitis. The jury also recommended against pancreatic debridement or drainage for sterile necrosis, limiting debridement or drainage to those with infected pancreatic necrosis and/or abscess confirmed by radiologic evidence of gas or results or fine needle aspirate. Furthermore, the jury recommended that whenever possible, operative necrosectomy and/or drainage be delayed at least 2-3 wk to allow for demarcation of the necrotic pancreas. CONCLUSIONS: This consensus statement provides 23 different recommendations concerning the management of patients with SAP. These recommendations differ in several ways from previous recommendations because of the release of recent data concerning the management of these patients and also because of the focus on the critically ill patient. There are a number of important questions that could not be answered using an evidence-based approach, and areas in need of further research were identified.