Critical Care Input Research Articles

WP3.16 - Comparing Outcomes in Acute Upper Gastrointestinal Bleeding: Initial Presentation versus In-hospital Incidence - A Single-Centre Investigation

Abstract Aims Acute upper gastrointestinal bleeding (AUGIB) is a gastrointestinal emergency with varied patient outcomes. We aimed to compare the outcomes of patients whose primary admission presentation was AUGIB versus inpatients who subsequently developed AUGIB as a complication. Methods This was a retrospective study of all adult patients receiving endoscopy for AUGIB in a single surgical unit from September 2021 to September 2022. Patient demographics, laboratory results, medical history and clinical progress, 30 and 90-day mortality were compared. Results 145 patients were identified, 75 (51.7%) were male and median age was 65 years (IQR 53-75). 117 presented to hospital with AUGIB (group 1) and 28 developed AUGIB as an inpatient (group 2). Median length-of-stay was 3.3 vs 10 days, respectively (p=0.014). Group 2 were more likely to present with symptomatic anaemia (p=0.001), higher National Early Warning System scores (p<0.001), shock (p<0.001), higher Glasgow-Blatchford score (p<0.001) and require blood transfusions (p<0.001). Group 2 had higher ASA Scores (p<0.001) and higher 30-day and 90-day all-cause mortality. No statistical correlations were noted regarding the distribution of endoscopic diagnoses obtained between both groups.Group 1(n=117)Group 2(n=28)P-Value30-Day all-cause Mortality4 (3.4%)4 (14.3%)0.02490-Day all-cause Mortality9 (7.7%)8 (28.6)0.002 Conclusion Our results echo previous studies that patients who develop AUGIB whilst an inpatient have significantly poorer outcomes. Causation is likely multifactorial and warrants further study. It remains important to closely apply the AUGIB care bundle and early critical care input to optimize outcome.

Optimising patient care: comprehensive evaluation of inpatient hypokalaemia.

Hypokalaemia is a common electrolyte disorder affecting hospitalised patients. It is associated with adverse outcomes including increased mortality. Inpatients with hypokalaemia need a different approach to workup and management as the aetiologies and progression of the hypokalaemia are distinct to outpatients. Potassium homeostasis is predominantly maintained by renal potassium handling. The clinical manifestations of hypokalaemia depend on the severity of hypokalaemia, however, most of the findings are non-specific. The approach to management is guided by the severity of the hypokalaemia and the underlying aetiology. Oral potassium replacement can be used in many cases of mild hypokalaemia. Intravenous replacement of potassium is necessary for many inpatients. Close monitoring is essential to ensure adequacy and to prevent adverse outcomes. An interdisciplinary approach with critical care input is needed in severe cases, and in patients where routine intravenous replacement may not be feasible (e.g., patients with heart failure). In addition to replacement, the cornerstone of management is a comprehensive review of the patient to identify the underlying cause of the hypokalaemia and the factors sustaining it. In patients in whom the cause is not apparent, or the potassium does not improve as anticipated, a referral to nephrology or endocrinology should be considered. This paper reviews the assessment of hypokalaemia in a hospital setting. It is aimed at early career doctors on the wards to help carry out a thorough evaluation. It also provides a useful framework for management.

Safety and Efficacy of Anakinra in Haemophagocytic Lymphohistiocytosis Associated with Acute Leukaemia

Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition in which immune hyperactivation and dysregulation results in a cytokine storm. It may be primary or secondary to infection, autoimmune disorders or malignancies (HLH-M). Lymphoma is the most widely described association in HLH-M; there is very limited data linking acute leukaemia and HLH. Current recommended treatments for HLH-M include steroids, IVIG and etoposide-containing regimens. In contrast, the recommended treatment in HLH- Macrophage activation syndrome is anti-IL1 directed therapy such as anakinra. In 2021 NHS England approved the use of anakinra to treat HLH of any cause, but the safety and efficacy data of anakinra in HLH-M is limited. We report a retrospective review of all patients diagnosed with HLH and acute leukaemia (AML) or acute lymphoblastic leukaemia (ALL) in a single London tertiary referral centre (University College London Hospitals NHS Foundation Trust (UCLH)), between 1 January2019 and 31 December 2022. We analysed electronic health records (EHR) of all patients diagnosed with ALL or AML and cross-referenced this with records of all patients referred to the UCLH HLH MDT. This identified 468 patients with acute leukaemia, of whom 13 (2.8%) were diagnosed with HLH. For diagnostic purposes, we utilised H scores (comprising laboratory and clinical parameters providing an HLH probability for each patient) using clinical and laboratory data collected from the EHR. HLH was diagnosed in patients with a clinical suspicion of HLH and an H score of >169. Patients were treated with various types of immunosuppressive therapy (IST). Twelve (92%) received anakinra, three (17%) of whom had anakinra monotherapy whilst the remainder had anakinra with steroids (38%), steroids and IVIG (15%), or steroids, IVIG and etoposide (8%). Anakinra was given intravenously in eleven patients and subcutaneously in one, with a mean daily dose of 4.6mg/kg. All patients required critical care input during their HLH treatment. Eight (62%) were admitted to intensive care unit (ICU) on diagnosis with HLH and required ventilatory and vasopressor support; the remainder were reviewed by critical care outreach. 92% patients had an initial rapid clinicopathological response following IST, becoming afebrile, reduction in oxygen requirement and haemodynamic stability seen within 24-72 hours. One patient (8%) had an initial clinical response to anakinra, methylprednisolone and IVIG triple therapy, but displayed subsequent rapid deterioration in the context of pseudomonal infection and died of multiorgan failure. Nine patients (69%) had no clinicopathological recurrence of HLH following initial treatment. Three (23%) had an initial clinical response to IST but had subsequent biochemical and clinical relapse of HLH. These patients all had relapsed/refractory disease on HLH recurrence. Only one (8%) patient died from HLH. Eight (62%) remain in remission from leukaemia at the end of the study period. Three patients (23%) died of refractory leukaemia, whilst a fourth patient is receiving palliative care for refractory disease. Although the link between HLH and lymphoma is well characterised, there is limited data on HLH in the context of acute leukaemia. In this case series, 2.8% of the patients treated with acute leukaemia developed HLH, which is comparable to the 3% for lymphoma quoted elsewhere. Although 92% of patients had microbiological or radiological evidence of infection on HLH diagnosis, many infections involved organisms not classically associated with HLH e.g. rhinovirus, indicating that the underlying leukaemia may play a central role in HLH-M pathogenesis. This is highlighted by the relapse of HLH which occurred alongside leukaemia relapse in three patients. Treatment responses and outcomes were favourable compared to the existing literature. Tamamyan et al reported an overall survival rate of 15% in 13 patients with HLH-M. Delavigne et al reported a three-month mortality rate of 36% in AML patients presenting with HLH during induction, compared to our figure of 23% for this time period and our overall survival rate of 62%. We believe this is the first case series demonstrating the effectiveness and high overall survival of HLH-M patients with concurrent leukaemia diagnosis using anakinra. Early treatment with anakinra alongside other immunosuppression may explain the trend towards improved outcomes in our cohort.

P-OGC30 High volume oesophagogastric resection in a small private hospital during COVID 19, April 2020- April 2021

BackgroundLike other hospitals at the peak of the pandemic, our institution had limited elective critical care capacity. This study summarises the outcomes of patients undergoing oesophagogastric (OG) resection at our institution, treated as the result of the emergency national contract between the NHS and the independent sector hospitals.MethodsPatients undergoing OG resection at our institution between April 2020 and April 2021 were included. Patients were managed through the multidisciplinary team and were treated according to standard ERAS pathways, involving critical care input. National OG Cancer Audit (NOGCA) metrics were collected and compared to pre-COVID data. Results81 patients underwent oesophagogastric resection in the private sector (60 oesophagectomies). Median length of stay was 9 days (9 pre-COVID). This included 21 patients who were repatriated to our main centre for ongoing management. 30-day mortality was 3.7% (1.8% pre-COVID), 90-day mortality 6.7% (4.2% pre-COVID). This included one patient who contracted COVID following discharge. 9 patients suffered an anastomotic leak, equating to a leak rate of 11% (7% pre-COVID). 22 resections were performed at our main centre (110-140 OG resection pre-COVID)ConclusionsIt is likely the private institution in this study represented one of the busiest oesophagogastric centres in the UK during COVID-19. A large cohort of patients underwent potentially curative surgery as a result of the emergency contract, who would have otherwise been placed on prolonged or palliative chemotherapy. 30 and 90-day mortality and anastomotic leak rates were higher than pre-pandemic levels, reinforcing the value of centralised tertiary OG resection services.

The obstetric patient in the Covid pandemic: anaesthesia and perioperative care.

: The Coronavirus Disease 2019 (COVID-19) pandemic has had an unprecedented impact on pregnant women, maternity services and healthcare workers. We review recent literature on the course of COVID-19 infection in pregnancy, and recommendations for treatment and service provision. It has been increasingly recognised that pregnant women are at higher risk of severe disease associated with COVID-19 infection. Early critical care input is crucial to guide respiratory support and techniques such as prone positioning, with a low threshold for intubation in critical illness. Timing of delivery remains a highly individualised decision. Following the RECOVERY trial, the use of a course of steroids in cases of severe COVID-19 infection has been widely adopted, and emerging guidance recommends vaccination in pregnant women. Rapidly emerging evidence has helped guide clinicians to identify those patients most at risk of severe disease in COVID-19 and implement early interventions to reduce morbidity and mortality.

940 Mesenteric Haematoma Complicated by A Perforated Sigmoid Diverticulum Following Extracorporeal Shockwave Lithotripsy

Abstract A 78 year old female presented with sudden onset lower abdominal pain, vomiting and fresh rectal bleeding. She had undergone extracorporeal shockwave lithotripsy (ECSL) for a left renal stone two weeks earlier and was taking Rivaroxaban for atrial fibrillation. A CT Abdomen & Pelvis revealed a large mesenteric haematoma and a contained sigmoid perforation secondary to compressive forces of the haematoma on the sigmoid artery, resulting in ischaemia. While mesenteric angiogram-guided embolisation initially controlled the active sigmoid artery bleed, the patient clinically deteriorated the following day warranting a laparotomy. This revealed an ischaemic sigmoid colon with contained faeculent material within the mesentery. An extended left hemi-colectomy with end-colostomy was performed. Despite optimal critical care input, the patient developed multi-organ failure and passed away one week later. Mesenteric haematoma should be considered as a rare complication in patients with sudden onset abdominal pain following ECSL; especially with concurrent anti-coagulation use.

Rapid Implementation of Telecritical Care Support During a Pandemic: Lessons Learned During the Coronavirus Disease 2020 Surge in New York City.

Objectives:We describe the key elements for a New York City health system to rapidly implement telecritical care consultative services to a newly created ICU during the coronavirus disease 2020 patient surge.Design:This was a rapid quality-improvement initiative using public health decrees, a HIPAA-compliant and device-agnostic telemedicine patform, and a group of out-of-state intensivist volunteers to enhance critical care support. Telecritical care volunteers initially provided on-demand consults but then shifted to round twice daily with housestaff in a 12-bed newly created ICU.Setting:A 457-bed safety net hospital in the Bronx, NY, during the pandemic.Subjects:The 12-bed newly created ICU was staffed by a telecritical care attending, a cardiology fellow, and internal medicine residents.Intervention:Prior to the intervention, the ad hoc ICU was staffed by a cardiology fellow as the attending of record, with critical care support on demand. The intervention involved twice daily rounding with an out-of-state, volunteer intensivist.Measurements and Main Results:Volunteers logged 352 encounters. Data from 26 unique encounters during the initial on-demand consult pilot study of tele-ICU support were recorded. The most common interventions were diagnostic test interpretation, ventilator management, and sedation change. The majority of housestaff felt the new tele-ICU service improved the quality of care of patients and decreased anxiety of taking care of complex patients. Likewise, the majority of volunteers expressed making significant alterations to care, and 100% believed critical care input was needed for these patients. The largest lessons learned centered around mandating the use of the telecritical care volunteers and integration into a structured format of rounding.Conclusions:The need for rapid implementation of ICUs during a major public health crisis can be challenging. Our pilot study supports the feasibility of using an out-of-state telecritical care service to support ICUs, particularly in areas where resources are limited.

37th International Symposium on Intensive Care and Emergency Medicine (part 2 of 3)

J McCartney, A MacKay, S Binning, C Wright Queen Elizabeth University Hospital, Glasgow, United Kingdom Introduction The Queen Elizabeth University Hospital opened in May 2015. The medical high dependency unit (MHDU) opened on 15/06/2015 – it predominantly provides level 2 care for medical patients, however multi-organ support (out with invasive mechanical ventilation and renal replacement therapy) can also be provided within MHDU if appropriate. The MHDU was run initially as an “open model” with admissions through on-call medical teams and their subsequent medical care being the admitting team’s responsibility. From 05/01/16 this system changed with a critical care consultant being based within the unit during the hours of 0800 -1800, Monday- Friday, their responsibility was to provide overall supervision of care, assess the appropriateness of admissions, and provide ongoing education and support for nursing and medical staff. The aim of this study was to evaluate the impact of this intervention on unit activity, outcomes, and quality metrics. Methods Retrospective, observational cohort study for purposes of service review. Local critical care database interrogated. Data on unit activity, unit outcomes, and quality metrics collected and period pre (15/06/15-04/01/16) and post (05/01/16-26/07/16) intervention compared by univariate analysis using MedCalc to detect significant changes following intervention. Results Post intervention there was a significant decrease in out of hours discharges (OOHDC) (pre 13%, post 6.7%, p = =2 (pre 63.8%, post 76.1%, p = <0.01). There was no significant change in unit mortality rate (pre 7.5%, post 9.7%, p = 0.18), readmission rate (pre 4%, post 5.2%, p = 0.35), rate of requirement for escalation to ICU (pre 7%, post 7.3%, p = 0.89), or median length of stay (pre 1.9 days, post 1.9 days, p = 0.87). Conclusions In our cohort, regular critical care input into MHDU was associated with a decrease in OOHDC rate and an increase in days spent at level 2 dependency or higher. The reduction in OOHDC was a desirable outcome given the association between OOHCDC and excess morbidity in critically ill patients. The increase in days at level 2 or higher dependency suggests a more appropriate use of the resource, it may also be suggestive of a sicker cohort of patients, it is interesting to note that there was no significant increase in unit mortality associated with this. We believe that regular input from clinicians with critical care training is beneficial in the MHDU.

TRIAGE OF SEPSIS PATIENTS: SIRS OR QSOFA – WHICH IS BEST?

Objectives & BackgroundRecent consensus guidelines have suggested using the qSOFA score as a tool for the identification of patients with sepsis outwith the ICU setting. In the UK, we currently...

ANAESTHETIC CHARTS IN ACUTE ICU ADMISSIONS: DEVELOPMENT FOR USE IN THE EMERGENCY DEPARTMENT

Objectives & BackgroundAnaesthetic charts are an invaluable source of concurrent and retrospective information. They provide relevant history and events during surgical and/or anaesthetic procedures. Admission notes to the intensive care...

DOES ADDING LACTATE TO THE NEWS SCORE IMPROVE IDENTIFICATION OF SEPTIC PATIENTS?

Objectives & BackgroundA previous audit has shown that in general with each rise in NEWS group there is an increase in serum lactate measured. However, it was noted that in...

Smoke inhalation increases intensive care requirements and morbidity in paediatric burns

Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burn's intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.

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Szakmany, Tamas1; Ellis, Gemma2; Lundin, Robert2; Pignatelli, Llaria2; Hall, Judith3; Morgan, Paul4 Author Information

Development of Australian clinical practice outcome standards for graduates of critical care nurse education.

To develop critical care nurse education practice standards. Critical care specialist education for registered nurses in Australia is provided at graduate level. Considerable variation exists across courses with no framework to guide practice outcomes or evidence supporting the level of qualification. An eDelphi technique involved the iterative process of a national expert panel responding to three survey rounds. For the first round, 84 statements, organised within six domains, were developed from earlier phases of the study that included a literature review, analysis of critical care courses and input from health consumers. The panel, which represented the perspectives of four stakeholder groups, responded to two rating scales: level of importance and level of practice. Of 105 experts who agreed to participate, 92 (88%) completed survey round I; 85 (92%) round II; and 73 (86%) round III. Of the 98 statements, 75 were rated as having a high level of importance - median 7 (IQR 6-7); 14 were rated as having a moderate level of importance - median 6 (IQR 5-7); and nine were rated as having a low level of importance - median 4 (IQR 4-6)-6 (IQR 4-6). The majority of the panel rated graduate level of practice as 'demonstrates independently' or 'teaches or supervises others' for 80 statements. For 18 statements, there was no category selected by 50% or more of the panel. The process resulted in the development of 98 practice standards, categorised into three levels, indicating a practice outcome level by the practitioner who can independently provide nursing care for a variety of critically ill patients in most contexts, using a patient- and family-focused approach. The graduate practice outcomes provide a critical care qualification definition for nursing workforce standards and can be used by course providers to achieve consistent practice outcomes.

Use of the high dependency unit, increased consultant involvement and reduction in adverse events in patients who die after colorectal cancer surgery

We prospectively audited adverse events for surgical patients with colorectal cancer who died under surgical care to test the hypothesis that increased critical care and consultant input could be associated with a reduction in adverse events. Patients with a diagnosis of colorectal cancer who died under surgical care in Scotland from 1996 to 2005 underwent peer review audit using established methodologies through the Scottish Audit of Surgical Mortality. In the 10-year study period, 3029 patients with colorectal cancer, mean age 76 (13-105)years, died under surgical care, of whom 80% had presented as an emergency admission. Operative intervention was performed in 1557 (51%) patients of whom 1030 (34%) patients had a resection of the cancer. The annual number of patients dying after a cancer resection decreased significantly (P=0.009). Significant decreases in adverse events were noted over time with a 67% fall in adverse events relating to critical care (P=0.009), a 37% fall for surgical care (P=0.04) and a significant increase in consultant anaesthetist and consultant surgeon input, but there was a 9% increase in delay as an adverse event (P=0.006). The documented anastomotic leakage rate in patients who died increased from 8% in 1996 to 19% in 2005 (P=0.016). The number of patients dying with colorectal cancer after surgery has decreased in recent years. Adverse events in these patients have significantly reduced over a decade with increased consultant involvement although there is the potential for further improvement.

Management of the critically ill obstetric patient

From 2006 to 2008, 261 women in the United Kingdom died either as a direct or indirect result of pregnancy. More than half of these received critical care input. The support required varied from observation and supportive management to multi-organ support. In many women death occurred despite optimal care, but in a number substandard care was identified when the cases were reviewed as part of the Confidential Enquiry into Maternal Deaths. An understanding of the different types of organ support and treatment that are available in a critical care setting and when these are indicated is therefore crucial for medical professionals caring for these unwell obstetric patients.Described here are the technical aspects of organ support that can be utilized in a critical care setting and the alterations in physiology that occur in pregnancy which influence the use of each treatment modality. Also highlighted in more detail are conditions that are common or life threatening in pregnancy and key points about management of these conditions when they mandate critical care support.

A Tragic Miscommunication: Ethical Decision Making in Burns Care

Patients with extensive burns injuries are often given a poor prognosis. Those who survive after an initial early resuscitation phase often require extensive operative and critical care input, a prolonged hospital stay, and associated significant complications. The overwhelmingly high volume of patients already using the resource-stricken burns care service places extreme pressure on clinicians in respect of decisions they make about who should and should not be resuscitated. In this paper, we present the case of a young woman who sustained significant burn injuries, and discuss the ethical dilemmas encountered during the subsequent management of her care.

Ethics in burns surgery: when is enough, enough?

Patients with extensive burns injuries are often given a poor prognosis. Those who survive after an initial early resuscitation phase often require extensive operative and critical care input, a prolonged hospital stay, and associated significant complications. The overwhelmingly high volume of patients already using the resource-stricken burns care service places extreme pressure on clinicians in respect of decisions they make about who should and should not be resuscitated. In this paper, we present the case of a young woman who sustained significant burn injuries, and discuss the ethical dilemmas encountered during the subsequent management of her care.

Intensive care management of patients with haematological malignancy

Serious complications are common among patients admitted to hospital with a diagnosis of haematological malignancy, with one British study of 1437 admissions identifying 7% as being complicated by an episode of critical illness. Although most of these episodes did not result in admission to intensive care unit (ICU), an increasing number of patients with a diagnosis of haematological malignancy are being managed within ICU or are receiving critical care input. Complication rates are higher for posthaematopoietic stem cell transplant (HSCT) patients with a recent abstract revealing an overall ICU admission rate for transplant patients of 13.6% among 1671 British patients over a 10 yr period. ICU admission for patients with haematological malignancies, and particularly after bone marrow transplantation, has been associated with very poor outcomes, and in some cases, critical care has been withheld because it was perceived to be futile. Newer studies suggest that ICU outcomes have improved, probably as a result of changes in both haematological treatments and ICU care. Patients with haematological malignancy may develop critical illness either as part of their first presentation with the malignancy or more commonly after chemotherapy or HSCT. Some presentations are specific to each scenario, whereas others may occur in all groups of patients. Respiratory failure is present in approximately half of all referrals to ICU. Between 10% and 50% of the patients have signs of shock, and there is evidence of multiple organ failure in about onefifth. Other causes for admission include neurological failure, gastrointestinal (GI) bleeding, renal failure, and metabolic derangement.