Worth a try or a last resort: Healthcare professionals' experiences and opinions of above cuff vocalisation.

BACKGROUND: Above cuff vocalisation (ACV) involves the application of an external flow of air via the subglottic port of a tracheostomy. ACV can facilitate vocalisation and may improve swallowing and quality of life for patients with a tracheostomy. A recent systematic review highlighted the limited evidence available for the acceptability, effectiveness, safety or optimal implementation of ACV. AIMS: To explore the experience of healthcare professionals (HCPs) using ACV and their perceptions of best practice. METHODS AND PROCEDURES: Semi-structured interviews were conducted with a range of HCPs with experience using ACV. Topics included: experiences with ACV, management of ACV, opinions about ACV, impact of COVID-19, future directions for ACV and impact on length of stay. Interviews were conducted online from December 2020 to March 2022. Data were analysed using reflexive thematic analysis. OUTCOMES AND RESULTS: Twenty-four HCPs were interviewed from seven countries and five professional groups. Four interconnected themes were developed: (1) moral distress amplifying the need to fix patients; (2) subjectivity and uncertainty leading to variations in practice and purpose; (3) knowledge and experience leading to control and caution; and (4) worth a try or a last resort. Theme four contained three sub-themes: (a) part of the toolbox; (b) useful but limited tool; and (c) following the patient's lead. The moral distress experienced by HCPs and their essential 'need to fix' patients seems to underpin the varied opinions of ACV. These opinions appear to be formed primarily on the basis of experience, because of the underlying subjectivities and uncertainties. As knowledge and experience with ACV increased, and adverse events were experienced, most HCPs became more cautious in their approach to ACV. CONCLUSIONS AND IMPLICATIONS: More research is needed to reduce the subjectivities and uncertainties surrounding ACV. The implementation of standardised procedures, processes, and competencies may help to reduce the frequency of adverse events and support a more controlled approach. Widening the focus of the purpose of ACV to include swallowing may help to maximise the potential benefits. WHAT THIS PAPER ADDS: What is already known on the subject There is limited and low-quality evidence for above cuff vocalisation (ACV) and clinical application and practice varies substantially. However, the reasons for this variation in practice and healthcare professionals' (HCPs') opinions of ACV were unclear. What this study adds HCPs' experiences and opinions of ACV vary as a result of the uncertainty and subjectivity surrounding ACV compounded by their personal experiences with it. A need for caution also appears to emerge as HCPs become more familiar and experienced with using ACV. What are the clinical implications of this work? Implementing standardised procedures, safety processes and competencies may help to compensate for the uncertainty and subjectivity surrounding ACV and may reduce the frequency of adverse events. Widening the focus of purpose of ACV, including swallowing in addition to communication, may increase the number of potential candidates and increase the potential benefits of ACV. Using multidisciplinary team (MDT) simulation training for ACV competency development might help to improve MDT working and ACV implementation.

The adaptation of the Leeds Post-Extubation Dysphagia Screen: Lessons learned during the COVID-19 pandemic.

Introduction: Post-extubation dysphagia (PED) can have serious consequences for critically unwell patients. COVID-19 has resulted in an increasing need for a PED screen in order to effectively identify patients and mitigate risk, whilst balancing under-resourced services. Online training provides the advantage of reducing time pressures on staff and supporting social distancing. This project aimed to adapt the Leeds Post-Extubation Dysphagia Screen (L-PEDS) and the associated training package to be more suitable and effective for use during COVID-19 pandemic. Methods: The screen was modified to a digital format with additional guidance for users. The training package was shortened and converted to an online package while keeping the interactive mode of training. Results: Preliminary results of 14 staff members indicate that the median confidence levels for screening patients for PED improved from 5 to 8 (on a scale of 0 to 10) after completing the L-PEDS-COVID training package. Likewise, knowledge of PED improved from a median of 4 to 8 (on a scale of 0 to 10). Training quality was rated at a median of 8 on a scale of 0 to 10 (0 being very poor; 10 being very good). Conclusions: Preliminary evidence demonstrated increased knowledge of PED and confidence in screening. The development of an adapted version of the L-PEDS and online training package may allow easier implementation of post-extubation dysphagia screening. This could help to compensate for insufficient speech and language therapy critical care staffing, assist in identifying patients at risk and improve outcomes by enabling earlier and safe resumption of oral intake.

Evidence for Above Cuff Vocalization in Patients With a Tracheostomy: A Systematic Review.

OBJECTIVES/HYPOTHESIS: To determine how above cuff vocalization (ACV) is implemented in clinical practice, to identify what evidence exists on the effectiveness and safety of ACV, and to evaluate the acceptability of ACV. STUDY DESIGN: Systematic review. METHODS: A literature search was conducted in eight databases (MEDLINE, Embase, AMED, CINAHL, Cochrane Library, PsycINFO, Scopus, and Web of Science) in May 2019 and updated in June 2020. Two reviewers independently screened, selected, and extracted data. Study quality was appraised using the Joanna Briggs Institute Critical Appraisal Tools and a narrative synthesis was conducted. Systematic review registration number: CRD42019133942. RESULTS: The searches identified 1327 records. The 13 eligible studies included four case studies, three case series, four observational studies without a control group, one quasi-experimental study, and one randomized controlled trial. Study quality was low, with most studies having high risk of bias. There was a high level of heterogeneity in study design and outcome measures used. Detailed information on ACV application and dose-delivered was lacking in 12 studies. Positive effects were reported for communication (n = 7), swallowing (n = 4), cough response (n = 2), and quality-of-life (n = 2), but with inconsistent use of objective outcome measures. There is limited quantitative or qualitative evidence for acceptability. Adverse events and complications were reported in nine studies, and four highlighted the importance of involving an experienced speech and language therapist. CONCLUSIONS: There is limited evidence for the acceptability, effectiveness, safety, or optimal implementation of ACV. The evidence is insufficient to provide recommendations regarding optimal intervention delivery. Future research should ensure detailed recording of ACV delivery and utilize a core outcome set. Laryngoscope, 132:600-611, 2022.

Determining the Prevalence, Implementation Approaches, and Opinions of Above Cuff Vocalization: A Survey of Health Care Professionals.

OBJECTIVE: To conduct an international survey to investigate the use of above cuff vocalization (ACV) and how practice and opinion differs. DESIGN: Observational, cross-sectional online survey. SETTING: Critical care, acute, rehabilitation, long-term care, and community. PARTICIPANTS: Health care professionals involved in tracheostomy care or weaning (N=243). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Tracheostomy management, prevalence, personal experiences and opinions, and barriers to use. Quantitative data were reported descriptively, and content analysis was conducted with qualitative data. RESULTS: The survey was completed by 243 health care professionals from 9 professional groups and 25 countries, with most responses from the United Kingdom (54%) and speech and language therapists (55%). ACV was used in 39% of services (n=93). Sixty percent (n=50/83) of health care professionals with direct experience of ACV had used it with <10 people. Implementation of ACV varied widely concerning procedures, contraindications, safety processes, professionals involved, competencies, staff training, delivery, and outcome measures. The top benefits were communication (n=76/93; 82%), mood (n=62/93; 67%), and laryngeal sensation (n=49/93; 53%). Complications included discomfort (n=54/93; 58%) and strained vocal quality (n=39/93; 42%). Barriers to ACV implementation included lack of knowledgeable staff (n=92/238; 39%) and lack of access to training (n=73/238; 31%). CONCLUSIONS: ACV uptake varies internationally with no standardized approach to ACV delivery. Diversity of opinions on approaches and benefits exist. Serious complications are infrequent, but minor complications are common. Future research is needed to establish optimal ACV implementation to maximize benefits and minimize risks.

Propofol infusion syndrome: a structured literature review and analysis of published case reports.

Propofol infusion syndrome is a rare, potentially fatal condition first described in children in the 1990s and later reported in adults. We provide a narrative review of what is currently known about propofol infusion syndrome, including a structured analysis of all published case reports; child and adult cases were analysed separately as propofol is no longer used for long-term sedation in children. The review contains an update on current knowledge of the pathophysiology of this condition along with recommendations for its diagnosis, prevention, and management. We reviewed 108 publications documenting 168 cases of propofol infusion syndrome. We evaluated clinical features and analysed factors influencing mortality in child and adult cases using separate multivariate analysis models. We used separate multiple linear regression models to analyse relationships between cumulative dose of propofol and the number of features seen and organ systems involved. Lipidaemia, fever, and hepatomegaly occurred more frequently in children than in adults, whilst rhabdomyolysis and hyperkalaemia were more frequent in adults. Mortality from propofol infusion syndrome is independently associated with fever and hepatomegaly in children, and electrocardiogram changes, hypotension, hyperkalaemia, traumatic brain injury, and a mean propofol infusion rate >5 mg kg-1 h-1 in adults. The cumulative dose of propofol was associated with an increased number of clinical features and the number of organ systems involved in adult cases only. Clinicians should consider propofol infusion syndrome in cases of unexplained metabolic acidosis, ECG changes, and rhabdomyolysis. We recommend early consideration of continuous haemofiltration in the management of propofol infusion syndrome.

Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure.

BACKGROUND: An acetominophen overdose (AOD) is the leading cause of acute liver failure (ALF) in the UK and USA. For patients who meet the King's College Hospital criteria, (mortality risk > 85%), an emergency orthotopic liver transplantation (OLT) is conventionally performed with subsequent life-long immunosuppression. A new technique was developed in 1998 for AOD-induced ALF where a subtotal hepatectomy (right hepatic trisectionectomy) and whole graft auxiliary liver transplant (WGALT) was performed with complete withdrawal of immunosupression during the first year post-operatively. RESULTS: During 1998-2010, 68 patients were listed for an emergency transplantation for AOD ALF at our institution: 28 died waiting, 16 underwent OLT and 24 a subtotal hepatectomy with WGALT. Eight OLT (50%) and 16 WGALT remain alive (67%); actuarial survival at 5 years OLT 50%, WGALT 63%, P = 0.37. All patients who had successful WGALT are off immunosuppression. Poor prognostic factors in the WGALT group included higher donor age (40.4 versus 53.9, P = 0.043), requirements for a blood transfusion (4.3 versus 7.6, P = 0.0043) and recipient weight (63.1 versus 54 kg, P = 0.036). CONCLUSION: Although OLT remains standard practice for AOD-induced ALF, life-long immunosuppression is required. A favourable survival rate using a subtotal hepatectomy and WGALT has been demonstrated, and importantly, all successful patients have undergone complete immunosuppression withdrawal. This technique is advocated for patients who have acetominophen hepatotoxicity requiring liver transplantation.

Biomarkers predicting sepsis in polytrauma patients: Current evidence.

INTRODUCTION: Major trauma still represents one of the leading causes of death in the first four decades of life. Septic complications represent the predominant causes of late death (45% of overall mortality) in polytrauma patients. The ability of clinicians to early differentiate between systemic inflammatory response syndrome (SIRS) and sepsis is demonstrated to improve clinical outcome and mortality. The identification of an "ideal" biomarker able to early recognize incoming septic complications in trauma patients is still a challenge for researchers. AIM: To evaluate the existing evidence regarding the role of biomarkers to predict or facilitate early diagnosis of sepsis in trauma patients, trying to compile some recommendations for the clinical setting. METHODS: An Internet-based search of the MEDLINE, EMBASE and Cochrane Library databases was performed using the search terms: "Biomarkers", "Sepsis" and "Trauma" in various combinations. The methodological quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies Checklist (QUADAS). After data extraction, the level of evidence available for each bio-marker was rated and presented using the "best-evidence synthesis" method, in line with the US Agency for Healthcare Research and Quality. RESULTS: Thirty studies were eligible for the final analysis: 13 case-control studies and 17 cohort studies. The "strong evidence" available demonstrated the potential use of procalcitonin as an early indicator of post-traumatic septic complications and reported the inability of c-reactive protein (CRP) to specifically identify infective complications. Moderate, conflicting and limited evidence are available for the other 31 biomarkers. CONCLUSION: Several biomarkers have been evaluated for predicting or making early diagnosis of sepsis in trauma patients. Current evidence does not support the use of a single biomarker in diagnosing sepsis. However, procalcitonin trend was found to be useful in early identification of post-traumatic septic course and its use is suggested (Recommendation Grade: B) in clinical practice.

Designing intelligent anesthesia for a changing patient demographic: a consensus statement to provide guidance for specialist and non-specialist anesthetists written by members of and endorsed by the Society for Obesity and Bariatric Anaesthesia (SOBA).

BACKGROUND: As a result of the increasing prevalence of obesity in the UK, anesthetists are increasingly encountering overweight and obese patients in routine practice. There is currently a paucity of evidence to guide best clinical practice for anesthetists managing overweight and obese patients. The current guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI), entitled Peri-Operative Management of the Morbidly Obese Patient, give an excellent overview of organizational issues, but leave much clinical detail to the discretion of the individual clinician. METHODS: In May 2010, a panel of experts convened to develop consensus on anesthesia of overweight, obese and morbidly obese patients, in consultation with the Society for Obesity and Bariatric Anaesthesia (SOBA). All Panel members are practicing clinicians from recognized bariatric surgical training centers and have extensive experience of anesthesia for obese patients. This statement aims to provide guiding principles on best practice for this challenging patient demographic, and to increase awareness of current issues so that these can be addressed more appropriately. RESULTS: In this document, we emphasize key principles for best practice, rather than giving prescriptive guidance and specific regimens for all clinical eventualities. We provide evidence-based justification for best-practice techniques, where this exists. In areas for which there is no evidence, but there is clear consensus, we offer this as guidance. We also aim to dispel misconceptions that have arisen in the anesthetic practice of overweight, obese, and morbidly obese patients. CONCLUSION: Ultimately, the choice of specific technique depends on clinician experience, patient characteristics, and center facilities. As well as providing guiding principles for anesthesia, this consensus statement also highlights other areas where anesthetists can contribute towards the enhanced recovery and overall quality of patient care.

The outcomes of critically ill patients with combined severe acute liver and kidney injury secondary to paracetamol toxicity requiring renal replacement therapy.

There is a paucity of outcome data for critically ill patients with combined acute liver and kidney injury secondary to paracetamol overdose (POD) requiring renal replacement therapy (RRT). We retrospectively reviewed all admissions over a 6-year period to the intensive care unit (ICU) at a university teaching hospital which supports an active liver transplant program. Of the 5582 admissions over this period, 73 patients were admitted with combined liver and kidney injury requiring RRT, and of these 10 patients went on to receive a liver transplant. Overall mortality was 58%, being lower at 20% for transplant recipients. Transplant recipients were younger than non-transplanted patients with similar global disease severity scores [Model for End-Stage Liver Disease (MELD) and Acute Physiology and Chronic Health Evaluation II (APACHE II)]. Patients with a higher MELD or APACHE II score fared worse and patients fulfilling the King's College Hospital transplant criteria on admission had an odds ratio (OR) for death of 3.8 (1.3-10.6). Logistic regression modeling found that only a higher admission bilirubin OR 1.6 (1.1-2.3) mg/dL and a lower creatinine OR 0.52 (0.3-0.9) mg/dL were predictive of mortality. Of the ICU survivors, 41% remained RRT dependant at the time of ICU discharge; all regained independent renal function by 1 month. Combined severe acute liver and kidney injury secondary to POD requiring RRT is associated with a high mortality. The majority of survivors recover independent kidney function by 1 month. Standard disease severity scores appear to reflect prognosis in these patients.

The outcomes of critically ill patients with acute kidney injury receiving renal replacement therapy.

INTRODUCTION: Acute kidney injury (AKI) is common among critically ill patients and associated with a high mortality. We report here on the outcomes of patients with AKI who received renal replacement therapy (RRT) on our intensive care unit (ICU). We were interested in which parameters measured at the time of ICU admission were predictive of mortality and the long term renal sequelae for these patients. PATIENTS AND METHODS: All ICU patients in a large UK teaching hospital who received RRT for AKI over a 6-year period were identified and reviewed retrospectively. RESULTS: There were 5582 admissions to ICU during this period of which 821 (14.7%) received RRT for AKI. The mean age was 59 years with ICU and hospital mortality rates of 55% and 66% respectively. Logistic regression analysis indicated that being older (OR 1.02 (1.01-1.03)) or having a lower pH (OR 0.07 (0.02-0.27)) or hemoglobin (OR 0.82 (0.74-0.91)) at the time of admission were predictive of mortality. Less than 7% of survivors were RRT dependant at hospital discharge and the majority had pre-existing renal impairment. For those patients with data available, there was a significant rise in the serum creatinine by 12 months post discharge (p<0.001). CONCLUSIONS: The mortality for critically ill patients receiving RRT for AKI is high, with two-thirds dying before hospital discharge. The requirement for long-term dialysis was 6.5% of survivors in our series which is much lower than that published elsewhere. Survivors of AKI who regained independent renal function had evidence of lasting renal injury.

Emergency subtotal hepatectomy: a new concept for acetaminophen-induced acute liver failure: temporary hepatic support by auxiliary orthotopic liver transplantation enables long-term success.

INTRODUCTION: Acetaminophen (paracetamol) overdose (AOD) has recently emerged as the leading cause of acute liver failure (ALF) in the United States, with an incidence approaching that seen in the United Kingdom. We describe a new way to treat AOD ALF patients fulfilling King's College criteria for "super-urgent" liver transplantation. METHODS: Beginning in June 1998, we have been piloting a clinical program of subtotal hepatectomy and auxiliary orthotopic liver transplantation (ALT) for AOD ALF. Our technique is based on the following principles: (1) subtotal hepatectomy; (2) auxiliary transplantation of a whole liver graft; (3) gradual withdrawal of immunosuppression after recovery. Results were compared with patients who had undergone an orthotopic liver transplantation (OLT) for AOD ALF in the same period. Quality of life comparisons were made using the SF36 questionnaire. RESULTS: Thirteen patients underwent this procedure between June 1998 and March 2005. Median survival is 68 months (range, 0-102 m). Actual survival data show that 9 of 13 patients are alive (69%) compared with 7 of 13 OLT patients (54%). One ALT patient required a retransplantation with an OLT due to hepatic vein thrombosis, and immunosuppression is therefore maintained. The other 8 surviving ALT patients are off immunosuppression. These 8 ALT patients have normal liver function and have a better quality of life compared with the 7 surviving OLT patients. CONCLUSION: Our results with this new technique are encouraging: 69% actual survival, no long-term immunosuppression requirement, and improved quality of life in the 62% successful cases.

The safety and efficacy of the use of vasopressin in sepsis and septic shock.

Sepsis remains a significant problem and cause of morbidity and mortality in intensive care. Vasopressin infusions are currently used as rescue therapy for the treatment of vasodilatory, catecholamine-resistant septic shock. At present, there are no large randomised, controlled trials in the literature investigating vasopressin in this role, although two such studies are currently ongoing in Canada. This review outlines the pathophysiology of sepsis and that of vasopressin in sepsis and reviews the available evidence for the use of vasopressin in sepsis and septic shock. A review of the safety data for vasopressin in this indication is included. Recommendations for the use of vasopressin in septic shock, along with suggestions for the direction of further work in the field are presented.

The safety and efficacy of the administration of recombinant activated factor VII in major surgery and trauma patients.

Recombinant activated Factor VII (rFVIIa) has been successfully used in the treatment of haemophilia A and B with associated inhibitors for some years. Activated Factor VII binds to activated platelets independently of tissue factor. The resulting stimulation of an exaggerated early thrombin burst at sites of vascular injury makes it an attractive potential treatment for massive, uncontrolled bleeding associated with surgery and trauma. This article describes the evidence relating to surgery and trauma. The lack of large, controlled trials of rFVIIa means that a definitive recommendation regarding its use cannot be made at present. However, in the context of clearly defined protocols and balanced treatment strategies, rFVIIa may have a role in traumatic bleeding. Large scale, randomised controlled trials in trauma are required, as is further work on the safety profile of rFVIIa with an independent international safety monitoring committee.

Management of polytraumatized patients with associated blunt chest trauma: a comparison of two European countries.

BACKGROUND: Blunt chest trauma represents one of the most common injuries in polytrauma patients. Blunt chest injury complicating polytrauma is associated with significant prolongation of intensive care stay. Further, it has a great impact on the timing of fixation of skeletal injuries, possibly contributing to adverse outcome. The purpose of this study is to assess whether there are any differences in the management and outcome of polytrauma patients with blunt chest trauma between trauma units in two different countries. Detailed information about advantages and disadvantages of these two systems might allow optimising the management of blunt chest trauma. PATIENTS AND METHODS: This investigation was performed using the polytrauma database of the German Trauma Society and the British Trauma Audit Research Network. After the definition of the inclusion abbreviated injury scale (AIS(chest) > or = 3) and injury severity score (ISS > 16) and exclusion (AIS(head/neck) > or = 2, referral from outside institutions) criteria, patients were recruited solely from these databases. RESULTS: 188 patients from the German database and 181 patients from the British database were enrolled in this study. Demographic data and injury pattern of the two patient populations did not significantly differ. The volume of initial red blood cell transfusion and length of the intensive care stay were significantly higher in Germany (p < 0.05). Mortality in the UK was 9% higher than in Germany (p = 0.057). Time to death in non-survivors was also significantly longer in Germany (p < 0.05). CONCLUSIONS: The reasons for the differences regarding survival times and survival rates seem to be multiple. German patients received more red blood cells, had a longer hospital stay in intensive care and a better survival rate. The use of kinetic therapy in Germany, not standard in the UK, may contribute to a more favourable outcome.

Complement membrane attack complex and hemodynamic changes during human orthotopic liver transplantation.

Hemodynamic changes and elevation of intracellular calcium following reperfusion in human liver transplantation occur rapidly and do not match the time course of cytokine expression, therefore, we postulate involvement of other, pre-formed substances, such as complement. We studied 40 adult patients undergoing liver transplantation. Blood was drawn for estimation of C3, C4, C3 degradation product, membrane attack complex, and CH100 levels and elastase (a marker of neutrophil activation) at induction of anesthesia, 5 minutes before reperfusion, 5 minutes and 60 minutes after reperfusion. Cardiac output was measured by thermodilution and systemic vascular resistance was calculated at these same time points. There was a significant rise in C5b-9 membrane attack complex (P =.0012) with a corresponding fall in C3 (P =.0013) and C4 (P =.0002) levels and a rise in C3 degradation product levels (P =.0006). There was no significant change in CH100. These changes very closely followed the hemodynamic changes of a significant fall in systemic vascular resistance index (P =.0024) and increase in cardiac index (P =.0005). Elastase rose from 356 +/- 53 to 557 +/- 40 microg/L (P <.0001). There is complement activation and neutrophil activation at reperfusion in liver transplantation. Dilution alone cannot explain the fall in C3 and C4 levels as there is a corresponding increase in membrane attack complex and C3 degradation product levels with time. As both C3 and C4 are consumed, the classical pathway must be active, though alternative and lectin activated pathways may also be involved. These findings may, at least in part, explain the hemodynamic changes typically seen at reperfusion in liver transplantation.

The effect of methylene blue on the hemodynamic changes during ischemia reperfusion injury in orthotopic liver transplantation.

UNLABELLED: After graft reperfusion in orthotopic liver transplantation (OLT), ischemia reperfusion syndrome (IRS) is characterized by persistent hypotension with a low systemic vascular resistance. Methylene blue (MB) has been used as a vasopressor in sepsis and acute liver failure. We investigated the effect of MB on IRS during OLT. Thirty-six patients undergoing elective OLT were randomized to receive either a bolus of MB 1.5 mg/kg before graft reperfusion, or normal saline (placebo). We recorded hemodynamic variables, postoperative liver function tests, and time to hospital discharge. Blood samples were analyzed for arterial lactate concentration, cyclic 3',5'-monophosphate, and plasma nitrite/nitrate concentrations. The MB group had higher mean arterial pressure (P = 0.035), higher cardiac index (P = 0.04), and less epinephrine requirement (P = 0.02). There was no difference in systemic vascular resistance or central venous pressure. Serum lactate levels were lower at 1 h after reperfusion in MB patients, suggesting better tissue perfusion (P = 0.03). In the presence of MB, there was a reduction in cyclic 3',5'-monophosphate (P < 0.001), but not plasma nitrites. Postoperative liver function tests and time to hospital discharge were the same in both groups. MB attenuated the hemodynamic changes of IRS in OLT acting via guanylate cyclase inhibition. IMPLICATIONS: Methylene blue attenuates the hemodynamic changes of the ischemia reperfusion syndrome in liver transplantation, and this effect involves guanylate cyclase inhibition.