Scoping review on diagnostic criteria and investigative approach in sepsis of unknown origin in critically ill patients.

BACKGROUND: Up to 11% of critically ill patients with sepsis have an unknown source, where the pathogen and site of infection are unclear. The aim of this scoping review is to document currently reported diagnostic criteria of sepsis of unknown origin (SUO) and identify the types and breadth of existing evidence supporting diagnostic processes to identify the infection source in critically ill patients with suspected SUO. METHODS: A literature search of Embase, MEDLINE and PubMed for published studies from 1910 to August 19, 2021 addressing the topic of SUO was performed. Study type, country of origin according to World Bank classification, diagnostic criteria of sepsis of unknown origin, and investigative approaches were extracted from the studies. RESULTS: From an initial 722 studies, 89 unique publications fulfilled the inclusion and exclusion criteria and were included for full text review. The most common publication type was case report/series 45/89 (51%). Only 10/89 (11%) of studies provided a diagnostic criteria of SUO, but a universally accepted diagnostic criterion was not identified. The included studies discussed 30/89 (34%) history, 23/89 (26%) examination, 57/89 (64%) imaging, microbiology 39/89 (44%), and special tests 32/89 (36%) as part of the diagnostic processes in patients with SUO. CONCLUSIONS: Universally accepted diagnostic criteria for SUO was not found. Prospective studies on investigative processes in critically ill patients managed as SUO across different healthcare settings are needed to understand the epidemiology and inform the diagnostic criteria required to diagnose SUO.

Endotracheal tube cuff pressure change: Proof of concept for a novel approach to objective cough assessment in intubated critically ill patients.

PURPOSE: Cough strength assessment aids in predicting extubation failure. Peak expiratory flow rate during cough manoeuvre (CPF) is the gold-standard tool and flow rates of <60l/min suggest risk of failed extubation. We aimed to assess endotracheal tube cuff pressure change (ΔPcuff) as a novel method of objective cough strength assessment in intubated patients considered for extubation. MATERIALS AND METHODS: Paired measurements of CPF and ΔPcuff were sampled during cough manoeuvres by intubated recovering critically ill patients. Spearman's correlation was used to assess agreement between the variables. Categorical data and receiver operating characteristic (ROC) curve analysis were undertaken to assess discriminating ability of ΔPcuff to identify low CPF. RESULTS: In total, 42 patients yielded 81 paired measurements. Paired samples with the highest CPF per patient had a correlation coefficient of 0.74. The composite of all samples had a correlation coefficient of 0.77. Regression analysis showed CPF=60l/min equates to ΔPcuff=28cmH2O with categorical analysis using these cut-offs showing significant dependence between the variables (p = 0.000001). ROC curve analysis identified an area under the curve (AUC) of 0.9 [95% CI (0.84, 0.97)], with optimal sensitivity and specificity of ΔPcuff at 20cmH2O. CONCLUSIONS: We identified a good correlation between CPF and ΔPcuff. Our research showed that overall discriminating ability of ΔPcuff in identifying CPF <60l/min was excellent. Further studies, looking at ΔPcuff and extubation outcomes are required to establish clinical utility.

Decision-making in ICU - A systematic review of factors considered important by ICU clinician decision makers with regard to ICU triage decisions.

BACKGROUND: The ICU is a scarce resource within a high-stress, high-stakes, time-sensitive environment where critically ill patients with life-threatening conditions receive expensive life-sustaining care under the guidance of expert qualified personnel. The implications of decisions such as suitability for admission into ICU are potentially dire and difficult. OBJECTIVES: To conduct a systematic review of clinicians' subjective perceptions of factors that influence the decision to accept or refuse patients referred to ICU. RESULTS: Twenty studies yielded 56 different factors classified into patient, physician and environmental. Common, important factors were: acute illness severity and reversibility; presence and severity of comorbidities; patient age, functional status, state-of-mind and wishes; physician level of experience and perception of patient QOL; and bed availability. Within-group variability among physicians and thought-deed discordance were demonstrated. CONCLUSIONS: The complex and dynamic ICU triage decision is affected by numerous interacting factors. The literature provides some indication of these factors, but fail to show complexities and interactions between them. A decision tree is proposed. Further research should include a reflection on how decisions for admission to ICU are made, such that a better understanding of these processes can be achieved allowing for improved individual and group consistency.

The role of transversus abdominis plane blocks in women undergoing total laparoscopic hysterectomy: a retrospective review.

INTRODUCTION: The transversus abdominis plane (TAP) local anaesthetic block is beneficial in patients undergoing open pelvic surgery; however, there are no data on its use in women undergoing laparoscopic gynaecologic surgery. METHODS: Successive women undergoing TLH were included in this review. All women had local anaesthetic infiltration at the site of port placement and, in addition, received multimodal post-operative analgesia. RESULTS: Sixty-one successive cases were included in the study: 20 had a TAP block and 41 were managed without any blocks. The groups were comparable with respect to age, body mass index, Eastern Co-operative Group performance status, type of operation, cancer status, surgical and anaesthetic time. Women with a TAP block had a significantly shorter length of stay (1.45 vs 2.20 days, P=0.014), lower total peri-operative and post-operative opioid use (12 vs 19 mg in morphine equivalents, P=0.014; 11 vs 21 mg, P=0.05) when compared with those without a TAP block. Multivariate analysis identified patient age and a TAP block with a shorter length of stay (P<0.001 and P=0.015, respectively). Total opioid use was only significantly correlated with a TAP block (P=0.005). There were no complications related to a TAP block. CONCLUSION: A TAP block in women undergoing TLH results in significantly shorter length of stay and lower opioid use. The retrospective nature of this trial and the absence of data on pain scores and nausea and vomiting are best addressed by a large prospective study.