The management of sepsis has substantially improved over the past 15 years. In this study, early, goal-directed therapy, which focuses on the initial resuscitation efforts, was compared with usual ...care for the management of severe sepsis in the United Kingdom.
The incidence of severe sepsis and septic shock in adults is estimated to range from 56 to 91 per 100,000 population per year.
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Affected patients have high rates of death, complications, and resource utilization.
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Since 2002, the Surviving Sepsis Campaign (SSC) has promoted best practice, including early recognition, source control, appropriate and timely antibiotic administration, and resuscitation with intravenous fluids and vasoactive drugs.
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Resuscitation guidance is largely based on a 2001 single-center, proof-of-concept study by Rivers et al., which indicated that protocolized delivery of 6 hours of early, goal-directed therapy (EGDT) to patients presenting to the emergency department . . .
Patients in intensive care units (ICUs) suffer from sleep deprivation arising from nursing interventions and ambient noise. This may exacerbate confusion and ICU-related delirium. The World Health ...Organization (WHO) suggests that average hospital sound levels should not exceed 35 dB with a maximum of 40 dB overnight. We monitored five ICUs to check compliance with these guidelines.
Sound levels were recorded in five adult ICUs in the UK. Two sound level monitors recorded concurrently for 24 hours at the ICU central stations and adjacent to patients. Sample values to determine levels generated by equipment and external noise were also recorded in an empty ICU side room.
Average sound levels always exceeded 45 dBA and for 50% of the time exceeded between 52 and 59 dBA in individual ICUs. There was diurnal variation with values decreasing after evening handovers to an overnight average minimum of 51 dBA at 4 AM. Peaks above 85 dBA occurred at all sites, up to 16 times per hour overnight and more frequently during the day. WHO guidelines on sound levels could be only achieved in a side room by switching all equipment off.
All ICUs had sound levels greater than WHO recommendations, but the WHO recommended levels are so low they are not achievable in an ICU. Levels adjacent to patients are higher than those recorded at central stations. Unit-wide noise reduction programmes or mechanical means of isolating patients from ambient noise, such as earplugs, should be considered.
Survivors of intensive care are known to be at increased risk of developing longer-term psychopathology issues. We present a large UK multicentre study assessing the anxiety, depression and ...post-traumatic stress disorder (PTSD) caseness in the first year following discharge from an intensive care unit (ICU).
Design: prospective multicentre follow-up study of survivors of ICU in the UK.
patients from 26 ICUs in the UK.
patients who had received at least 24 h of level 3 ICU care and were 16 years of age or older.
postal follow up: Hospital Anxiety and Depression Score (HADS) and the Post-Traumatic Stress Disorder (PTSD) Check List-Civilian (PCL-C) at 3 and 12 months following discharge from ICU.
caseness of anxiety, depression and PTSD, 2-year survival.
In total, 21,633 patients admitted to ICU were included in the study. Postal questionnaires were sent to 13,155 survivors; of these 38% (4943/13155) responded and 55% (2731/4943) of respondents passed thresholds for one or more condition at 3 or 12 months following discharge. Caseness prevalence was 46%, 40% and 22% for anxiety, depression and PTSD respectively; 18% (870/4943 patients) met the caseness threshold for all three psychological conditions. Patients with symptoms of depression were 47% more likely to die during the first 2 years after discharge from ICU than those without (HR 1.47, CI 1.19-1.80).
Over half of those who respond to postal questionnaire following treatment on ICU in the UK reported significant symptoms of anxiety, depression or PTSD. When symptoms of one psychological disorder are present, there is a 65% chance they will co-occur with symptoms of one of the other two disorders. Depression following critical illness is associated with an increased mortality risk in the first 2 years following discharge from ICU.
ISRCTN Registry, ISRCTN69112866 . Registered on 2 May 2006.
Purpose
Discharge from an intensive care unit (ICU) out of hours is common. We undertook a systematic review and meta-analysis to explore the association between time of discharge and mortality/ICU ...readmission.
Methods
We searched Medline, Embase, Web of Knowledge, CINAHL, the Cochrane Library and OpenGrey to June 2017. We included studies reporting in-hospital mortality and/or ICU readmission rates by ICU discharge “out-of-hours” and “in-hours”. Inclusion was limited to patients aged ≥ 16 years discharged alive from a non-specialist ICU to a lower level of hospital care. Studies restricted to specific diseases were excluded. We assessed study quality using the Newcastle Ottowa Scale. We extracted published data, summarising using a random-effects meta-analysis.
Results
Our searches identified 1961 studies. We included unadjusted data from 1,191,178 patients from 18 cohort studies (presenting data from 1994 to 2014). “Out of hours” had multiple definitions, beginning between 16:00 and 22:00 and ending between 05:59 and 09:00. Patients discharged out of hours had higher in-hospital mortality relative risk (95% CI) 1.39 (1.24, 1.57)
p
< 0.0001 and readmission rates 1·30 (1.19, 1.42),
p
< 0.001 than patients discharged in hours. Heterogeneity was high (
I
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90.1% for mortality and 90.2% for readmission), resulting from differences in effect size rather than the presence of an effect.
Conclusions
Out-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. These effects persisted across all definitions of “out of hours” and across healthcare systems in different geographical locations. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear.
Thwaites Glacier is one of the largest, most rapidly changing glaciers on Earth, and its landward-sloping bed reaches the interior of the marine West Antarctic Ice Sheet, which impounds enough ice to ...yield meters of sea-level rise. Marine ice sheets with landward-sloping beds have a potentially unstable configuration in which acceleration can initiate or modulate grounding-line retreat and ice loss. Subglacial water has been observed and theorized to accelerate the flow of overlying ice dependent on whether it is hydrologically distributed or concentrated. However, the subglacial water systems of Thwaites Glacier and their control on ice flow have not been characterized by geophysical analysis. The only practical means of observing these water systems is airborne ice-penetrating radar, but existing radar analysis approaches cannot discriminate between their dynamically critical states. We use the angular distribution of energy in radar bed echoes to characterize both the extent and hydrologic state of subglacial water systems across Thwaites Glacier. We validate this approach with radar imaging, showing that substantial water volumes are ponding in a system of distributed canals upstream of a bedrock ridge that is breached and bordered by a system of concentrated channels. The transition between these systems occurs with increasing surface slope, melt-water flux, and basal shear stress. This indicates a feedback between the subglacial water system and overlying ice dynamics, which raises the possibility that subglacial water could trigger or facilitate a grounding-line retreat in Thwaites Glacier capable of spreading into the interior of the West Antarctic Ice Sheet.
Heterogeneous hydrologic, lithologic, and geologic basal boundary conditions can exert strong control on the evolution, stability, and sea level contribution of marine ice sheets. Geothermal flux is ...one of the most dynamically critical ice sheet boundary conditions but is extremely difficult to constrain at the scale required to understand and predict the behavior of rapidly changing glaciers. This lack of observational constraint on geothermal flux is particularly problematic for the glacier catchments of the West Antarctic Ice Sheet within the low topography of the West Antarctic Rift System where geothermal fluxes are expected to be high, heterogeneous, and possibly transient. We use airborne radar sounding data with a subglacial water routing model to estimate the distribution of basal melting and geothermal flux beneath Thwaites Glacier, West Antarctica. We show that the Thwaites Glacier catchment has a minimum average geothermal flux of ∼114 ± 10 mW/m ² with areas of high flux exceeding 200 mW/m ² consistent with hypothesized rift-associated magmatic migration and volcanism. These areas of highest geothermal flux include the westernmost tributary of Thwaites Glacier adjacent to the subaerial Mount Takahe volcano and the upper reaches of the central tributary near the West Antarctic Ice Sheet Divide ice core drilling site.
To determine the prevalence of post traumatic stress disorder in survivors of intensive care treatment.
Systematic literature review including Medline, Embase, CINAHL, PsycINFO and references from ...identified papers.
Studies determining the prevalence of PTSD in adult patients who had at least 24Symbol: see texth treatment on an intensive care unit. Independent duplicate data extraction. Study quality was evaluated in terms of study design and method and timing of PTSD assessment. DATA SYNTHESIS AND RESULTS: Of the 1472 citations identified, 30 studies meeting the selection criteria were reviewed. PTSD was diagnosed by standardised clinical interview alone in 2 studies. A self-report measure alone was used in 19 studies to measure PTSD symptomatology. The remaining 9 studies applied both standardised clinical interview and a self-report measure. The reported prevalence of PTSD was 0-64% when diagnosed by standardised clinical interview and 5-64% by self-report measure. PTSD assessments occurred 7 days to 8 years after intensive care discharge.
The true prevalence of PTSD and the optimum timing and method of PTSD assessment have not yet been determined in intensive care unit survivors. Deficiencies in design, methodology and reporting make interpretation and comparison of quoted prevalence rates difficult, and rigorous longitudinal studies are needed.
High-frequency oscillatory ventilation has been advocated for hypoxemia accompanying the acute respiratory distress syndrome. In this trial comparing HFOV with conventional ventilation, HFOV had no ...significant effect on 30-day mortality.
The acute respiratory distress syndrome (ARDS) is a severe, diffuse inflammatory lung condition caused by a range of acute illnesses. Mortality in affected patients is high,
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and survivors may have functional limitations for years.
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Although mechanical ventilation can initially be lifesaving in patients with ARDS, it can also further injure the patients' lungs and contribute to death.
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High-frequency oscillatory ventilation (HFOV) was first used experimentally in the 1970s to minimize the hemodynamic effects of mechanical ventilation.
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Patients' lungs are held inflated to maintain oxygenation, and carbon dioxide is cleared by small volumes of gas moved in and out of . . .
There is conflicting evidence on harm related to exposure to supraphysiologic Pa
(hyperoxemia) in critically ill patients.
To examine the association between longitudinal exposure to hyperoxemia and ...mortality in patients admitted to ICUs in five United Kingdom university hospitals.
A retrospective cohort of ICU admissions between January 31, 2014, and December 31, 2018, from the National Institute of Health Research Critical Care Health Informatics Collaborative was studied. Multivariable logistic regression modeled death in ICU by exposure to hyperoxemia.
Subsets with oxygen exposure windows of 0 to 1, 0 to 3, 0 to 5, and 0 to 7 days were evaluated, capturing 19,515, 10,525, 6,360, and 4,296 patients, respectively. Hyperoxemia dose was defined as the area between the Pa
time curve and a boundary of 13.3 kPa (100 mm Hg) divided by the hours of potential exposure (24, 72, 120, or 168 h). An association was found between exposure to hyperoxemia and ICU mortality for exposure windows of 0 to 1 days (odds ratio OR, 1.15; 95% compatibility interval CI, 0.95-1.38;
= 0.15), 0 to 3 days (OR 1.35; 95% CI, 1.04-1.74;
= 0.02), 0 to 5 days (OR, 1.5; 95% CI, 1.07-2.13;
= 0.02), and 0 to 7 days (OR, 1.74; 95% CI, 1.11-2.72;
= 0.02). However, a dose-response relationship was not observed. There was no evidence to support a differential effect between hyperoxemia and either a respiratory diagnosis or mechanical ventilation.
An association between hyperoxemia and mortality was observed in our large, unselected multicenter cohort. The absence of a dose-response relationship weakens causal interpretation. Further experimental research is warranted to elucidate this important question.
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