Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service.

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS® (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.

Pain and symptom relief using inhaled methoxyflurane for gynecologic brachytherapy applicator removal.

Purpose: Intra-cavitary brachytherapy forms an essential part of the curative treatment of cervical and vaginal cancer, and can be used for cure or palliation in endometrial and vulval cancers. Removal of brachytherapy applicators is often performed after anaesthesia has worn off and can be an uncomfortable and anxiety-provoking procedure. In this paper, we present our experience in a series of patients before and after the introduction of inhaled methoxyflurane (IMF, Penthrox™). Material and methods: Questionnaires were sent to patients prior to the introduction of IMF to retrospectively score pain and anxiety during the brachytherapy procedure. Following successful review by the local drugs and therapeutic committee as well as staff training, IMF was introduced and offered to patients during applicator removal. Prospective pain scores and retrospective questionnaires were collected. Pain was rated on a scale of 0 to 10, with zero being no pain and 10 being extreme pain. Results: Thirteen patients returned retrospective questionnaires prior to IMF introduction and seven patients following IMF introduction. After the first brachytherapy insertion, the mean recollected pain score during applicator removal decreased from 6/10 to 1/10 (p = 0.002). The mean recollected pain score one hour after applicator removal reduced from 3/10 to 0 (p = 0.04). Prospective measurements for 77 insertions in 44 patients receiving IMF reported a median pain score of 1/10 immediately before applicator removal (range, 0-10), and 0/10 immediately after applicator removal (range, 0-5). Conclusions: Inhaled methoxyflurane is easily administered and effective method of decreasing pain during applicator removal following gynecologic brachytherapy.

FUSIC HD. Comprehensive haemodynamic assessment with ultrasound.

FUSIC haemodynamics (HD) - the latest Focused Ultrasound in Intensive Care (FUSIC) module created by the Intensive Care Society (ICS) - describes a complete haemodynamic assessment with ultrasound based on ten key clinical questions: 1. Is stroke volume abnormal? 2. Is stroke volume responsive to fluid, vasopressors or inotropes? 3. Is the aorta abnormal? 4. Is the aortic valve, mitral valve or tricuspid valve severely abnormal? 5. Is there systolic anterior motion of the mitral valve? 6. Is there a regional wall motion abnormality? 7. Are there features of raised left atrial pressure? 8. Are there features of right ventricular impairment or raised pulmonary artery pressure? 9. Are there features of tamponade? 10. Is there venous congestion? FUSIC HD is the first system of its kind to interrogate major cardiac, arterial and venous structures to direct time-critical interventions in acutely unwell patients. This article explains the rationale for this accreditation, outlines the training pathway and summarises the ten clinical questions. Further details are included in an online supplementary appendix.

Safety and Feasibility Assessment of Repetitive Vascular Occlusion Stimulus (RVOS) Application to Multi-Organ Failure Critically Ill Patients: A Pilot Randomised Controlled Trial.

Muscle wasting is implicated in the pathogenesis of intensive care unit acquired weakness (ICU-AW), affecting 40% of patients and causing long-term physical disability. A repetitive vascular occlusion stimulus (RVOS) limits muscle atrophy in healthy and orthopaedic subjects, thus, we explored its application to ICU patients. Adult multi-organ failure patients received standard care +/- twice daily RVOS {4 cycles of 5 min tourniquet inflation to 50 mmHg supra-systolic blood pressure, and 5 min complete deflation} for 10 days. Serious adverse events (SAEs), tolerability, feasibility, acceptability, and exploratory outcomes of the rectus femoris cross-sectional area (RFCSA), echogenicity, clinical outcomes, and blood biomarkers were assessed. Only 12 of the intended 32 participants were recruited. RVOS sessions (76.1%) were delivered to five participants and two could not tolerate it. No SAEs occurred; 75% of participants and 82% of clinical staff strongly agreed or agreed that RVOS is an acceptable treatment. RFCSA fell significantly and echogenicity increased in controls (n = 5) and intervention subjects (n = 4). The intervention group was associated with less frequent acute kidney injury (AKI), a greater decrease in the total sequential organ failure assessment score (SOFA) score, and increased insulin-like growth factor-1 (IGF-1), and reduced syndecan-1, interleukin-4 (IL-4) and Tumor necrosis factor receptor type II (TNF-RII) levels. RVOS application appears safe and acceptable, but protocol modifications are required to improve tolerability and recruitment. There were signals of possible clinical benefit relating to RVOS application.

An Economic Analysis of Critical Care Nurse Resourcing Following the Uptake of Ready-to-Administer Noradrenaline for Hypotensive Shock in Adults in England.

INTRODUCTION: Ready-to-administer formulations for intravenous administration of noradrenaline are now broadly recommended and predicted to reduce pressure on critical care nursing. This analysis sought to quantify the nurse resource released from national level transition. METHODS: The annual number of noradrenaline support days for hypotensive shock was determined and the administration of noradrenaline was simulated over 24 h using a decision tree. A 'best-practice' ready-to-administer strategy (RtA) of volumetrically pumped noradrenaline was compared to a 'nil uptake' strategy (AfC) of bedside prepared solution delivered either volumetrically or using a double syringe pump. A mix of noradrenaline concentrations, flow rates, product sizes, and preferences for ampoule pooling, preparation volume, and sterility were included. The consumption of nurse days and product units was then projected over 1 year for a population of adults in critical care in England. RESULTS: Noradrenaline was administered over 231,011 days per year across 4123 critical care beds in England. Implementing a transition from AfC to RtA strategies on this scale released 35,791 nurse days or 176 whole-time nurse equivalents at 50/50 NHS band 5 and 6, a monetised release of £11.6 million. There was an increase in drug acquisition cost of £2.1 million using the licensed commercial product Sinora®. Annual net monetary benefit was + £9.5 million, or + £65,961 per critical care unit (CCU) of 29 beds, equivalent to one nurse released per unit for patient care. CONCLUSIONS: This modelling of ready-to-administer noradrenaline with volumetric delivery quantifies and bears out the recommendations of the Lord Carter review, the Royal Pharmaceutical Society, and the NHS Specialist Pharmacy Service in their encouragement of ready-to-administer formulations for safe and resource-effective critical care.

Review of management in cardiotoxic overdose and efficacy of delayed intralipid use.

We present the case of a 51-year-old woman admitted to our intensive care unit following an intentional overdose of a calcium channel antagonist and a beta blocker. The resultant hypotension was reversed with glucagon, noradrenaline, calcium and high-dose insulin. Despite these interventions, she remained vasoplegic and received a delayed, standard dose of intralipid. Subsequently, the vasoplegia resolved rapidly, and the vasopressor was stopped. Here, we review the management of overdose of calcium channel and beta-adrenergic receptor blockers, concentrating on the pharmacology of lipid emulsion therapy. There remain some unanswered questions about lipid emulsion therapy: treatment with lipid therapy is usually advocated as soon as possible; this case report suggests that it remains efficacious even if its administration were delayed.

Free Open Access Med(ical edu)cation for critical care practitioners.

Free Open Access Med(ical edu)cation refers to an online community of knowledge relating to medicine. Originating from practitioners in emergency medicine, it has since spread to critical care, internal medicine, prehospital medicine, paediatrics, and allied health professionals and continues to grow at an advanced rate. Weblogs ('blog' for short), emails, social media (in particular Twitter), recorded audio material ((podcasts), and video material are all produced on a daily basis and contribute to the continual professional development of trainees and consultants worldwide. In this article, we explain its background, rise to prominence, and explore some of its controversies.

Iatrogenic forearm compartment syndrome.

Limb compartment syndrome may be sequelae of trauma, but in the context of critical care blood sampling, arterial damage may have profound consequences. We describe a series of three cases and their progress and discuss guidelines for prevention of this potentially devastating occurrence in critically ill patients.