Haemodynamic changes during prone versus supine position in patients with COVID-19 acute respiratory distress syndrome.

BACKGROUND: Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES: The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS: We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS: We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION: Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

Surgical consent practice in the UK following the Montgomery ruling: A national cross-sectional questionnaire study.

BACKGROUND: The Supreme Court case of Montgomery vs Lanarkshire Health Board in 2015 was a landmark case for consent practice in the UK which shifted focus from a traditional paternalistic model of consent towards a more patient-centered approach. Widely recognised as the most significant legal judgment on informed consent in the last 30 years, the case was predicted to have a major impact on the everyday practice of surgeons working in the UK National Health Service (NHS). Two years after the legal definition of informed consent was redefined, we carried out an audit of surgical consent practice across the UK to establish the impact of the Montgomery ruling on clinical practice. MATERIALS & METHODS: Data was collected by distribution of an electronic questionnaire to NHS doctors working in surgical specialities with a total of 550 respondents. RESULTS: 81% of surgical doctors were aware of the recent change in consent law, yet only 35% reported a noticeable change in the local consent process. Important barriers to modernisation included limited consent training, a lack of protected time for discussions with patients and minimal uptake of technology to aid decision-making/documentation. CONCLUSIONS: On the basis of these findings, we identify a need to develop strategies to improve the consent process across the NHS and limit the predicted rise in litigation claims.

Cardiac arrest: a missed learning opportunity.

AIM: The Resuscitation Council advocates debriefing after cardiac arrests, as both a training tool and to improve patient outcomes. There is, however, a large variation between hospitals in their implementation of debriefing. This potentially disadvantages trainees, as they are unable to use the presented opportunity to improve their skills and knowledge. The primary aim of this survey was to investigate the utility and perception of debriefing postcardiac arrest among staff at a district general hospital. The secondary aim was to evaluate our specifically designed postcardiac arrest debrief tool. METHOD: A confidential, qualitative survey was distributed to 100 cardiac arrest team members at Lister Hospital, Stevenage, during February 2016. RESULTS: 72% of the participants reported never having debriefed postcardiac arrest at Lister Hospital. 93% believed that debriefing would improve individual performance, 95% felt it would benefit team performance and 88% felt it would improve patient safety. Our postcardiac arrest debrief tool was well received, with 93% stating that they would find the tool useful. CONCLUSIONS: Debriefing postcardiac arrest has been associated with improved return of spontaneous circulation (ROSC) neurological outcomes, hands-off compression times as well as reduced time delay to first compression. Despite the benefits, this survey has shown a lack of debriefing at our hospital. We have developed a concise debriefing tool aimed at providing much-needed training for those involved. The tool allows identification of key concerns in leadership, and teamwork and encourages open discussions around areas of concern. We believe that its implementation may improve resuscitation outcomes, and therefore, recommend its use postcardiac arrests.