Intensive Care National Audit And Research Centre Research Articles

Severe acute pancreatitis in the era of endoscopically placed lumen-apposing metal stents (LAMS): critical care outcomes from a large UK pancreatobiliary centre

Objectives1. Describe characteristics of patients with severe acute pancreatitis (SAP) requiring admission to Critical Care, including interventional management of pancreatic fluid collections.2. Quantify whether patients requiring drainage of collections via...

Trends in organ donation in England, Scotland and Wales in the context of the COVID-19 pandemic and 'opt-out' legislation.

In May 2020, England implemented soft 'opt-out' or 'deemed consent' for deceased donation with the intention of raising consent rates. However, this coincided with the COVID-19 pandemic, making it difficult to assess the early impact of the law change. Wales and Scotland changed their organ donation legislation to implement soft opt-out systems in 2015 and 2021 respectively. This study provides a descriptive analysis of changes in consent and transplant rates for deceased organ donation in England, Scotland and Wales. Logistic regression and descriptive trend analysis were employed to assess the probability of a patient who died in critical care becoming a donor, and to report consent rates using data, respectively, from the Intensive Care National Audit and Research Centre (ICNARC) in England from 1 April 2014 to 30 September 2021, and from the Potential Donor Audit for England, Scotland and Wales from April 2010 to June 2023. The number of eligible donors in April-June 2020 were 56.5%, 59.3% and 57.6% lower in England, Scotland and Wales relative to April-June 2019 (pre-pandemic). By April-June 2023, the number of eligible donors had recovered to 87.4%, 64.2% and 110.3%, respectively, of their levels in 2019. The consent rate in England, Scotland and Wales reduced from 68.3%, 63.0% and 63.6% in April-June 2019 to 63.2%, 60.5% and 56.3% in April-June 2023. While the UK organ donation system shows signs of recovery from the COVID-19 pandemic, the number of eligible potential donors and consent rates remain below their pre-pandemic levels.

External Validation of Prognostic Models in Critical Care: A Cautionary Tale From COVID-19 Pneumonitis

OBJECTIVES (BACKGROUND): To externally validate clinical prediction models that aim to predict progression to invasive ventilation or death on the ICU in patients admitted with confirmed COVID-19 pneumonitis. DESIGN: Single-center retrospective external validation study. DATA SOURCES: Routinely collected healthcare data in the ICU electronic patient record. Curated data recorded for each ICU admission for the purposes of the U.K. Intensive Care National Audit and Research Centre (ICNARC). SETTING: The ICU at Manchester Royal Infirmary, Manchester, United Kingdom. PATIENTS: Three hundred forty-nine patients admitted to ICU with confirmed COVID-19 Pneumonitis, older than 18 years, from March 1, 2020, to February 28, 2022. Three hundred two met the inclusion criteria for at least one model. Fifty-five of the 349 patients were admitted before the widespread adoption of dexamethasone for the treatment of severe COVID-19 (pre-dexamethasone patients). OUTCOMES: Ability to be externally validated, discriminate, and calibrate. METHODS: Articles meeting the inclusion criteria were identified, and those that gave sufficient details on predictors used and methods to generate predictions were tested in our cohort of patients, which matched the original publications’ inclusion/exclusion criteria and endpoint. RESULTS: Thirteen clinical prediction articles were identified. There was insufficient information available to validate models in five of the articles; a further three contained predictors that were not routinely measured in our ICU cohort and were not validated; three had performance that was substantially lower than previously published (range C-statistic = 0.483–0.605 in pre-dexamethasone patients and C = 0.494–0.564 among all patients). One model retained its discriminative ability in our cohort compared with previously published results (C = 0.672 and 0.686), and one retained performance among pre-dexamethasone patients but was poor in all patients (C = 0.793 and 0.596). One model could be calibrated but with poor performance. CONCLUSIONS: Our findings, albeit from a single center, suggest that the published performance of COVID-19 prediction models may not be replicated when translated to other institutions. In light of this, we would encourage bedside intensivists to reflect on the role of clinical prediction models in their own clinical decision-making.

Ovarian Hyperstimulation Syndrome (OHSS) requiring Intensive Care Unit (ICU) admission between 1996-2020 in England, Wales, and Northern Ireland.

Ovarian Hyperstimulation Syndrome (OHSS) is a life-threatening iatrogenic complication of In vitro fertilisation (IVF). This study aimed to quantify rates of Ovarian Hyperstimulation Syndrome (OHSS) requiring intensive care unit (ICU) admission and assess whether trends have changed between 1996-2020 commensurate with the introduction of safer IVF practices. Data regarding Intensive Care Unit (ICU) admission across England, Wales and Northern Ireland was gathered retrospectively from the Intensive Care National Audit and Research Centre (ICNARC) database. 38,957 female patients aged between 18-55 years were admitted to ICU for OHSS or related conditions between 1996-2020. The primary outcome was the rate of OHSS requiring ICU admission expressed as a proportion of the number of fresh IVF cycles conducted in that year according to Human Fertility and Embryology Authority (HFEA) records. Baseline characteristics (for example, age, ethnicity, BMI), biochemical parameters (such as renal function, serum electrolytes), length of ICU stay and duration and need for organ support, were also compared between ICU patients with 'confirmed OHSS' and those 'without OHSS'. There were 238 cases of 'confirmed OHSS' requiring ICU admission recorded between 1996-2020. Rates of OHSS requiring ICU admission declined over the study period (P=0.006); the annual rate of severe OHSS requiring intensive care admission halved when comparing those occurring between 1996-2007 and 2008-2020 (OR=0.37, 95% CI 0.37-0.45; P<0.0001). Patients spent a mean of 3.5 days in the ICU, with 86.3% of patients with 'confirmed OHSS' requiring at least 2 days of higher level (i.e., level 2 or 3) care. Patients with 'confirmed OHSS' required a shorter duration of renal, advanced cardiovascular, and advanced respiratory support than patients 'without OHSS' (P<0.0001 for all comparisons). There was no significant difference in BMI or ethnicity between those with 'confirmed OHSS' and those 'without OHSS', however women with 'confirmed OHSS' were younger (34 versus 41 years old, p<0.0001). Although absolute rates of OHSS requiring ICU admission recorded in this study are likely to represent a significant underestimate of all clinically significant OHSS, rates of OHSS requiring ICU admission have decreased since 1996 in concordance with the introduction of modern IVF practices.

Severe mental illnesses and mortality following COVID-19 infection: Data linkage study using the Clinical Practice Research Database (CPRD).

BackgroundThe association of COVID-19 infection with death in people with severe mental illnesses (SMI), and the relationship to multimorbidities/ underlying health conditions ethnicity is unclear. Health records linked to COVID-19 tests data could help to inform this knowledge gap.&#x0D; ObjectiveTo determine the risk of death in people with SMI following COVID-19 infection compared to reference groups and assess whether excess mortality is accounted through underlying health conditions or further elevated in minority ethnic groups.&#x0D; Design, setting and participantsNationally representative cohort study using primary care data from the Clinical Practice Research Database (CPRD), with participants followed from the start of the pandemic in 2020, for 1.5 years, covering England, Wales and Northern Ireland. For consenting practices, CPRD data was linked to COVID-19 data Public Health England (PHE) Second Generation Surveillance System (SGSS), PHE COVID-19 Hospitalisation in England Surveillance System (CHESS), and Intensive Care National Audit and Research Centre (ICNARC) data on COVID-10 intensive care admissions. The cohort comprised 795,836 individuals, with 7,493 individuals with SMI and a positive COVID-19 test (“SMI/COVID-19”). Comparison groups were: 2,325 individuals with SMI/ testing negative for COVID-19 (“SMI/ non COVID-19”), 657,414 individuals from a non-SMI group/ testing positive for COVID-19 (“non-SMI/ COVID-19”), and 128,604 individuals from a non-SMI group/ testing negative for COVID-19 (“non-SMI/ non-COVID-19”).&#x0D; ExposuresSMI defined as the presence of schizophrenia, schizoaffective disorder, bipolar disorder, or affective disorders with psychosis, according to the International Classification of Mental Disorders (ICD-10). COVID-19 diagnoses identified through confirmed laboratory tests and clinical diagnoses.&#x0D; OutcomesAll-cause mortality&#x0D; ResultsA higher proportion of SMI patients with COVID-19 were obese (37% versus 22% in the non-SMI/non-COVID-19 group), current smokers (27% versus 23% in the non-SMI/non-COVID-19 group), had underlying health conditions, and were Black Caribbean/ Black African (5% versus 1% in the non-SMI/non-COVID-19 group). Relative to the non-SMI/ non-COVID-19 group, the SMI/ COVID-19 group had an elevated risk of death (age and sex-adjusted hazard ratio (aHR) 5.03 (95%CI: 4.61-5.54)). This was elevated to a lesser extent, in the SMI/ non COVID-19 group (aHR: 1.93 (95%CI: 1.54-2.41)) and in the non-SMI/ COVID-19 group (aHR: 2.85 (95%CI: 2.72-2.98). Excess risk persisted after adjusting for tobacco use, weight and comorbidities. Mortality trends were similar across groups by ethnicity. Risk of death was highest for the SMI/ COVID-19 group during the first wave of infection in the UK, however excess mortality was still evident and substantially elevated at the second wave also.&#x0D; ConclusionsPeople living with SMI are at an increased risk of death compared to population controls; this excess risk is further elevated following COVID-19 infection, with similar trends by ethnicity. Underlying health conditions only partially account for deaths following COVID-19 infection in this group.

Admission patterns and outcomes of postoperative oral cavity and oropharyngeal cancer patients admitted to critical care in the UK: an analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database

Surgery for head and neck malignancy may be complex with postoperative admission to critical care units (CCUs) often required. There are, however, increasing demands on this resource. We examined a national intensive care database to assess patterns of admission and outcomes for patients following surgery for malignancies of the oral cavity and oropharynx. An analysis was performed of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme database. Data were extracted on case mix and outcomes for patients coded as ‘malignant neoplasm of the oropharynx requiring surgery’ admitted to critical care between 2010 and 2019. Data included admission numbers, demographics, comorbidities, physiology scores, and outcomes including length of stay and mortality. There were 9,843 admissions for patients with malignancies of the oral cavity and oropharynx from 156 CCUs over the ten-year period. Admissions increased from 486 in 2010 to 1,381 in 2019. These admissions accounted for 0.42% of overall admissions in 2010 and 0.78% in 2019. The median age of patients was 63 years and 63.5% were male. The median length of stay in critical care was 38 hours (Interquartile range (IQR) 20.4-64.3 hours). The median length of total hospital stay was 15 days (IQR 10-23 days). Mortality in critical care was low (0.7%). Admissions to CCUs following surgery for malignancies of the oral cavity and oropharynx have increased over the last decade but remain low overall. With increasing demand for this resource, ongoing monitoring of utilisation is important.

Admission patterns and outcomes of patients admitted to critical care in the UK with surgically treated facial infection: an analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database

Facial infections are common and can occasionally be severe. A small number of patients may develop severe sepsis or airway compromise requiring critical care admission. We examined a national intensive care database to assess patterns of admission and outcomes for patients in this cohort. An analysis was performed of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme database. Data were extracted on case mix and outcomes for patients coded as ‘mandible, facial bones, dental, and salivary infection’ admitted to critical care between 2010 and 2019. Data included admission numbers, demographics, comorbidities, physiology scores, and outcomes including length of stay and mortality. There were 2820 admissions for patients with facial infections from 212 CCUs over the ten-year period. Admissions increased from 194 in 2010 to 368 in 2019. These admissions accounted for 0.16% of overall admissions in 2010 and 0.21% in 2019, a statistically significant increase in the rate of admissions, p < 0.001. The median age of patients was 48 years and 62.7% were male. Sepsis was present in 77.6% of patients. The median length of stay in critical care was 49 hours (IQR 23.2, 100.3 hours). The median total hospital stay was 7 days (IQR 4, 16 days). The rate of admissions to CCUs for facial infection remains low overall but has significantly increased over the last decade. With increasing demand for this resource ongoing monitoring of utilisation is important.

COVID-19 highlights the need to optimize critical care resource use: The role of a respiratory-led multidisciplinary team.

COVID-19 highlights the need to optimize critical care resource use: The role of a respiratory-led multidisciplinary team.

Identification of pathophysiological patterns for triage and respiratory support in COVID-19

In the UK, more than 279 392 cases of COVID-19 had been documented by June 3, 2020, and more than 39 500 patients had died with the disease, according to the COVID-19 web-based dashboard at Johns Hopkins University.1 Data derived from the UK Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database show that, for the first 8062 patients admitted to the ICU across the UK with documented outcomes, by May 29, 2020, about 72% received advanced mechanical ventilation and the mortality rate was around 53%.

Short- and long-term outcomes of patients with solid tumours following non-surgical intensive care admission.

There has been a significant increase in the number of patients presenting with cancer related emergencies and potentially requiring critical care admission. To analyse the short and long-term outcomes of patients with solid tumours requiring unplanned medical admission to a specialist cancer intensive care unit (ICU). An unplanned cohort study. A retrospective analysis of patients admitted to a UK specialist tertiary oncology CCU between September 2009 and September 2015. The primary outcome measures were survival to CCU discharge and 1-year survival. 687 patients had an unplanned medical admission. The most frequent primary tumours were lymphoma (22.1%), lung (15.2%) and colorectal (13.0%), and 181 (44.4%) were known to have metastases. The median Acute Physiology and Chronic Health Evaluation (APACHE) II and Intensive Care National Audit and Research Centre (ICNARC) scores were 21 and 17, respectively. ICU mortality was 26.7%, with total hospital mortality of 41.9%. The median survival of the total cohort was 56 days after ICU admission, with 107 patients surviving 365 days. Patients with metastatic disease were almost twice as likely to die within the year following ICU admission compared with their counterparts without metastases. Only pancreatic and lung primaries were shown to have a statistically significant impact on survival at 1 year. Pneumonia carried with it the worst prognosis (cumulative survival 0.11), followed by sepsis (0.25) and non-infective respiratory disease (0.26). The stage and type of cancer appear to have minimal impact on short-term ICU outcomes and only confer poorer long-term prognosis related to the disease.

The use of multi-sourced linked datasets in evaluating the Emergency Medical Retrieval and Transfer Service (EMRTS) CYMRU

ABSTRACT&#x0D; ObjectivesEMRTS launched in April 2015 which saw consultants join critical care practitioners on air ambulance missions and emergency response vehicles. EMRTS delivers pre hospital, Emergency Department equivalent critical care for people in Wales with life or limb threatening injuries or illness from scene to definitive care. The evaluation will compare patients treated by EMRTS to cases both pre-EMRTs and EMRTS-offline (at night or bad weather) in improving survival and functional and quality of life outcomes.&#x0D; ApproachThe evaluation will require the use of multiple datasets to follow patients from time of incident, throughout hospital care and to calculate post care health status. Electronic reporting forms will be used to measure incident details, patient vitals and all treatments/procedures pre hospital, creating the EMRTS dataset and cohort. Patients’ data will be linked to the Emergency Department Dataset (EDDS), Patient Episode Database for Wales (PEDW), Critical Care dataset, Trauma Audit and Research Network (TARN) and Intensive Care National Audit and Research Centre (ICNARC). TARN and ICNARC will provide data on patients transferred to English specialist care facilities.&#x0D; ONS (Office of National Statistics) and WDS (Welsh Demographic Service) data will be used for demographic and survival analysis.&#x0D; GIS techniques will be used on WAST (Welsh Ambulance Service Trust) data for time saved analysis in transferring patients to definitive care.&#x0D; Following discharge from hospital patients will be interviewed six months and one-year post incident for longer-term functional and quality of life outcomes.&#x0D; ResultsDatasets are currently being assembled for the service evaluation. Data will be encrypted and anonymized through NWIS (NHS Wales Informatics Service) to enable research through the Secure Anonymised Information Linkage (SAIL) facility. Results will include rate of survival, effect on length of hospital stay, time to definitive care, the use and appropriateness of EMRTs specific interventions and functional and quality of life outcomes.&#x0D; ConclusionsTo allow for data collection the service evaluation is still in the early stages and will be compared with local and international data.

Early versus late readmission of subarachnoid haemorrhage patients into neurocritical care

Introduction: Subarachnoid haemorrhage (SAH) patients will typically require monitoring in a specialised Neurocritical Care Unit (NCCU) regardless of the primary treatment modality. Once discharged from NCCU, readmission within 48 h is regarded as a “failed” discharge. The aims of this study are to (1) Evaluate the readmission rate of SAH patients into NCCU, (2) Identify the indications for readmission, (3) Analyse clinical parameters on discharge between patients readmitted early and late.Materials and methods: Retrospective observational study of the Intensive Care National Audit and Research Centre (ICNARC) database of patients from our unit diagnosed with SAH from January 2009–December 2014, who were readmitted into NCCU. Demographic data, World Federation of Neurosurgical Societies (WFNS) grade, Fisher grade, length of initial and subsequent NCCU stay, time of readmission, indication for readmission, and mortality rate data were collected. Patients were categorised by early (<48 h) and late (>48 h) readmission, and their clinical parameters on NCCU discharge were statistically analysed.Results: Five hundred and seventy-five SAH patients were admitted into NCCU, of which 49 patients (9%) were readmitted after discharge to ward-level care. The mean age of readmitted patients was 64.1 ± 11.6 years old. The most common indications were delayed cerebral ischaemia (DCI) (50%) and infection (19%). Readmitted SAH patients were typically WFNS grade I–II (n = 22) and Fisher grade III–IV (n = 44). 17 (35%) patients were readmitted early, and were older (p = 0.0049) with a lower GCS (p = 0.0077) compared to patients readmitted later. White cell count and C-reactive protein were higher in patients readmitted early, but did not reach statistical significance (p = 0.09, p = 0.07).Conclusion: DCI and infection were the most common indications for NCCU readmission in SAH patients. “Failed” discharged patients from NCCU are typically older with a lower GCS than patients readmitted after 48 h, and therefore clinicians should be more cautious in discharging these patients prematurely.

Does Preoperative Beta-blocker Use Influence Intraoperative Hemodynamic Profile and Post-operative Course of Liver Transplantation?

ObjectiveWe compared the intraoperative hemodynamic profiles and outcomes of liver transplant (LT) patients receiving preoperative beta-blockers for portal hypertension with those of patients not receiving beta-blockers. MethodsBeat-to-beat hemodynamic data were recorded with the use of a lithium dilution cardiac output monitor, including heart rate (HR), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), SVR index, mean arterial pressure, stroke volume (SV), and SV index. Perioperative data included age, sex, etiology of cirrhosis, Model of End-Stage Liver Disease score, warm and cold ischemia times, and intraoperative blood and blood products replacement. Postoperative data included Acute Physiology and Chronic Health Evaluation II score, Intensive Care National Audit and Research Centre (ICNARC) score, length of intensive care unit stay, renal replacement treatment, and mortality. ResultsAfter exclusion, 215 patients not receiving and 93 patients receiving beta-blockers for portal hypertension were included. There was no significant difference between groups in demographic data. HR, CO, and CI were significantly lower in the beta-blocker group (P = .0001). Regarding outcomes, the ICNARC score was significantly higher in the beta-blocker group (P < .05). ConclusionsPreoperative administration of beta-blockers attenuates the hyperdynamic circulation in LT patients; this is clearly seen through a reduction in intraoperative CO, CI, and HR. This decreased hyperdynamic state was not shown to relate to outcomes in any of the variables except for a higher ICNARC score reported in the group treated with beta-blockers.

Intensive Care Foundation Research Poster Presentations

Introduction: Over the last 25 years there has been significant work carried out in producing risk prediction models for patients admitted to critical care units. The most recent of these models is the Intensive Care National Audit and Research Centre (ICNARC) model developed in 2007 (1) which uses data from 231,930 admissions to 163 critical care units to develop and validate a UK based model outperforming other approaches (with an average c index of 0.863). Aims: This research aims to present an artificial neural network based model for critical care admissions that improves over the ICNARC model in terms of the discrimination across the data set used in this study. Results: Figure 1 shows a comparison between the receiver operator characteristics (ROC) curve for our artificial neural network (ANN) model and the ICNARC model presented in (1). This figure shows the ROC curve and point-wise confidence intervals for the true positive values of both our model (in blue) and the ICNARC model (in red). In comparison, our artificial neural network classification model produces an average c value of 0.8983 in 10 fold cross validation of our data compared to a c value of 0.8306 for the ICNARC model using the same data set (consisting of 642 patients admitted to North Middlesex Hospital critical care unit over a 28 month period. Data excludes 432 patients where data was incomplete). Conclusion: Our classification model provides a percentage risk score that outperforms the ICNARC model. This classification model does suffer from some of same issues surrounding the ICNARC model – for instance, the influence of some of the parameters within both models can be unclear to clinicians trying to predict the survival of individual patients. However, further work is ongoing to improve the transparency of this model

Validation of the Intensive Care National Audit and Research Centre Scoring System in a UK Adult Cardiac Surgery Population.

The Intensive Care National Audit and Research Centre (ICNARC) scoring system was conceived in 2007, utilizing 12 physiologic variables taken from the first 24 hours of adult admissions to the general intensive care unit (ICU) to predict in-hospital mortality. The authors aimed to evaluate the ICNARC score in predicting mortality in cardiac surgical patients compared to established cardiac risk models such as logistic EuroSCORE as well as to the Acute Physiology and Chronic Health Evaluation (APACHE) II. Retrospective analysis of data collected prospectively. Single-center study in a cardiac intensive care in a regional cardiothoracic center. Patients undergoing cardiac surgery between January 2010 and June 2012. A total of 1,646 patients were scored preoperatively using the logistic EuroSCORE and postoperatively using ICNARC and APACHE II. Data for comparison of scoring systems are presented as area under the receiver operating characteristic curve. The mean age at surgery was 67 years±10.1. The mortality from all cardiac surgery was 3.2%. The mean logistic EuroSCORE was 7.31±10.13, the mean ICNARC score was 13.42±5.055, while the mean APACHE II score was 6.32±7.731. The c-indices for logistic EuroSCORE, ICNARC, and APACHE II were 0.801, 0.847 and 0.648, respectively. The authors have, for the first time, validated the ICNARC score as a useful predictor of postoperative mortality in adult cardiac surgical patients. This could have implications for postoperative management, focusing the utilization of resources as well as a method to measure and compare performance in the cardiothoracic ICU.

Age influences the predictive value of Acute Physiology and Chronic Health Evaluation II and Intensive Care National Audit and Research Centre scoring models in patients admitted to Intensive Care Units after in-hospital cardiac arrest.

Introduction:Outcomes following in-hospital cardiac arrest (IHCA) are generally poor though different patient populations may benefit to different degrees from admission to Intensive Care Units (ICUs). Risk stratification algorithms may be useful in identifying patients who are most likely to benefit from ICU admission and so may aid allocation of this scarce resource. We aimed to compare the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Intensive Care National Audit and Research Centre (ICNARC) scoring systems in predicting outcome following ICU admission after IHCA in younger (≤69 years) and older (≥70 years) patients.Materials and Methods:We performed a retrospective observational study in two adult ICUs from January 2006 to February 2010 inclusive. Patients were divided into younger (≤69 years) and older (≥70 years) patients. The primary outcome measures were acute hospital mortality and area under the curve (AUC) calculation for receiver operating characteristic (ROC) analysis.Results:Two hundred and sixty-one adult consecutive adult patients admitted following IHCA. Hospital mortality was 58.6%. ROC analysis demonstrated that ICNARC was more accurate than APACHE II in predicting acute hospital outcomes in the adult population (AUC 0.734 vs. 0.706). Both scoring systems performed weaker when predicting outcomes in younger patients compared to older patients (ICNARC AUC 0.655 vs. 0.810; APACHE II AUC 0.660 vs. 0.759).Discussion:Both APACHE II and ICNARC predict outcome well in older patients. In younger patients, their value is less clear, and so they must be used with caution.

Pre-ICU length of hospital stay is a predictor of hospital but not ICU mortality

Prolonged hospital stay prior to admission to the ICU was previously shown to be independently associated with poorer outcome [1,2]. This is probably due to slow deterioration of physiological function in hospital and influenced by processes leading to critical care admission [2]. We investigated whether commonly measured severity scoring systems (Acute Physiology and Chronic Health Evaluation (APACHE) II, Intensive Care National Audit and Research Centre (ICNARC) and Sequential Organ Failure Assessment (SOFA) scores) are significantly different in patients admitted with prolonged pre-ICU hospital length of stay, and describe mortality and hospital length of stay.

ICNARC STUDY OF MORTALITY IN NEUROLOGICAL PATIENTS ON ICU

In many countries, treatment of life-threatening neurological conditions takes place in specialised Neuro-Critical Care Units (NCCU). In the UK most patients are treated on general intensive care units (GICU) with varying levels neurological support. We used the Intensive Care National Audit and Research Centre (ICNARC) database to analyse mortality for ICH, MG and GBS between 1996 and 2009 in NCCU and ICUs in the UK. For ICH (n=10,313), overall ICU mortality was 42.4% and acute hospital mortality 62.1%. In NCCU length of stay was longer, but mortality lower, and over time, mortality from ICH decreased faster. For MG (n=1,064) and GBS (n=1,906) there was no association between acute hospital mortality unit type–overall mortality was relatively high (MG: 8.7% ICU mortality and 22% acute hospital mortality; GBS: 7.7 and 16.7% respectively). Overall mortality did not decrease over time. The first large-scale analysis of outcome in acute neurological disease in UK shows specialised NCCU care alone is associated with increased survival in conditions requiring highly specialised intensive care techniques. The high mortality seen after ICU discharge particularly in MG and GBS suggests that high quality step-down care and neurorehabilitation is pivotal in others.

Acute neuromuscular respiratory failure: a population-based study of aetiology and outcome in Northern Ireland

BackgroundAcute neuromuscular respiratory failure (NMRF) is a life-threatening feature of a variety of neurological conditions that can present in extremis prior to the establishment of a definitive diagnosis, so early...

Survey on the Use of Gentamicin and Vancomycin in Adult Intensive Care Units

Aminoglycosides and glycopeptides are frequently used as empirical antibiotics in critically ill patients. Various nomograms are employed to monitor and adjust doses either as once daily or more frequent regimens. However, there is no universal guidance for their administration and monitoring. We conducted a survey, using an online questionnaire, of adult intensive care units (ICUs) across England, Wales and Northern Ireland, to ascertain prescribing and monitoring practices. ICUs listed on the Intensive Care National Audit and Research Centre (ICNARC) register were invited to participate. A total of 242 intensive care units were approached and 24.3% responded (n=59). Of those responding, 100% (n=59) used gentamicin to treat gram-negative infections, with 96.6% (n=57) of them using a once daily regimen and 11.9% (n=7) using multiple doses daily. An initial gentamicin dose of 5mg/kg was used by 53.4% (n=31), whereas 25.9% (n=15) used a concentration of 7 mg/kg. With regard to use of glycopeptides, vancomycin was used by 83.1% (n=49) of responders while 61% (n=36) used teicoplanin. Over two-thirds of responders (67.3%, n=35) indicated that they used vancomycin as an intermittent daily dose and 32.7% (n=17) used it as a continuous infusion. We conclude that diversity exists as to the use and monitoring of aminoglycosides and glycopeptides within the ICUs surveyed. Most of the clinicians stopped antibiotics based on clinical assessment rather than a predetermined duration (eg five days or seven days) and a small number of units used procalcitonin to guide antibiotic therapy.