Sleeping on a problem: the impact of sleep disturbance on intensive care patients - a clinical review

Sleep disturbance is commonly encountered amongst intensive care patients and has significant psychophysiological effects, which protract recovery and increases mortality. Bio-physiological monitoring of intensive care patients reveal alterations in sleep architecture, with reduced sleep quality and continuity. The etiological causes of sleep disturbance are considered to be multifactorial, although environmental stressors namely, noise, light and clinical care interactions have been frequently cited in both subjective and objective studies. As a result, interventions are targeted towards modifiable factors to ameliorate their impact. This paper reviews normal sleep physiology and the impact that sleep disturbance has on patient psychophysiological recovery, and the contribution that the clinical environment has on intensive care patients' sleep

Personalised fluid resuscitation in the ICU: Still a fluid concept?

The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful. New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used. Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient’s context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid. The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous

Fluid resuscitation in human sepsis: Time to rewrite history?

Fluid resuscitation continues to be recommended as the first-line resuscitative therapy for all patients with severe sepsis and septic shock. The current acceptance of the therapy is based in part on long history and familiarity with its use in the resuscitation of other forms of shock, as well as on an incomplete and incorrect understanding of the pathophysiology of sepsis. Recently, the safety of intravenous fluids in patients with sepsis has been called into question with both prospective and observational data suggesting improved outcomes with less fluid or no fluid. The current evidence for the continued use of fluid resuscitation for sepsis remains contentious with no prospective evidence demonstrating benefit to fluid resuscitation as a therapy in isolation. This article reviews the historical and physiological rationale for the introduction of fluid resuscitation as treatment for sepsis and highlights a number of significant concerns based on current experimental and clinical evidence. The research agenda should focus on the development of hyperdynamic animal sepsis models which more closely mimic human sepsis and on experimental and clinical studies designed to evaluate minimal or no fluid strategies in the resuscitation phase of sepsi

Development of a Clinical Simulation Protocol for the Transfer of a Premature Fetal Manikin to the Perinatal-Life-Support System

Introduction:At present, Perinatal-Life-Support (PLS) research is progressing to offer extreme premature infants an extracorporeal environment for extended growth that mimics the natural womb closely. During the early phase development of this novel life-support technology, validation and training could be facilitated by the use of a medical simulation. By doing so, the need for animal testing can be greatly reduced. Within this abstract, the development to realize a wellorchestrated clinical simulation protocol is described, tailored to the specific needs of novel procedure(s) regarding the transfer of a premature fetus from the maternal uterus to the PLS system.Materials & Methods:Throughout protocol development an iterative approach is used, initiated with a literature analysis and a review of existing obstetrics guidelines for premature births. Next, co-creation sessions and interviews with medical and engineering experts led to a holistic understanding of fetal physiology, patient and specialist needs, current procedures, task divisions, hospital resources and drug specifications. Expert feedback on drafts, checklists and an explanatory step-by-step video, led to multiple re-designs as unforeseen procedural difficulties arose. Verified with available data from literature, multiple perspectives and options were analyzed and weighed to ensure the advancement of a safe, hygienic, effective, and user-friendly simulation protocol.Results:We describe the development process of a simulation protocol and showcase an overview of the current protocol design through an infographic, outlining the different phases and tasks during a transfer procedure and the planning of involved medical experts within the operating theatre. We demonstrate that an iterative approach to protocol development for an unprecedented procedure allows for a comprehensive understanding of the challenges that a transfer to the PLS-system could bring.Conclusions:Using medical simulation during the early phase development process of the PLS-system allows us to train and validate novel practices, in particular the transfer procedure. With the demonstrated approach we aim to establish a thorough simulation protocol by providing a step-by-step plan, informed by literature and expert consultation. We expect to offer a realistic simulation training whilst also informing requirements for the future development of PLS-related devices and their validation

The bereavement experiences of families of potential organ donors:a qualitative longitudinal case study illuminating opportunities for family care

OBJECTIVES: To illuminate opportunities for care in the context of deceased organ donation by exploring pre-existing family and healthcare professional characteristics, in-hospital experiences, and ongoing adjustment through the lenses of grief theory, systems theory, meaning-making, narrative, and organ donation literature. METHOD: Qualitative longitudinal case studies explored individual and family change in five Australian families who had consented to Donation after Circulatory Determination of Death at a single centre. Participants attended semi-structured interviews at four, eight, and twelve months after the death. FINDINGS: Family values, pre-existing relationships, and in-hospital experiences influenced first responses to their changed lives, understanding of the patient’s death, and ongoing family adjustment. Novel behaviour that was conguent with family values was required at the hospital, especially if the patient had previously played a key role in family decision-making. This behaviour and emerging interactional patterns were drawn into family life over the first year of their bereavement. RECOMMENDATIONS: Training that includes lenses introduced in this study will enable healthcare professionals to confidently respond to individual and family psychosocial needs. CONCLUSION: The lenses of grief theory and systems thinking highlight opportunities for care tailored to the unique in-hospital context and needs that emerge in the months that follow

Sleep monitoring techniques within Intensive Care

Sleep is an essential biological function that provides important restorative psycho-physiological processes. Patients in the Intensive Care Unit are highly vulnerable to sleep disturbance which can protract their recovery. Despite sleep disturbance being widely acknowledged amongst this patient cohort, the ability to make significant changes to minimise the burden of sleep deprivation remains a challenge. This is further compounded by the difficulties faced by clinicians to identify and implement accurate and feasible sleep monitoring techniques in the intensive care. Whilst objective, behavioural and subjective methods of sleep assessment exist, all have specific limitations when applied to critically ill patients. In an attempt to illuminate these issues, current sleep monitoring techniques are appraised

Fluid resuscitation in sepsis: the great 30 mL per kg hoax

Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation

Long-term follow-up for Psychological stRess in Intensive CarE (PRICE) survivors:Study protocol for a multicentre, prospective observational cohort study in Australian intensive care units

Introduction There are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting. Methods and analysis This will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members. Ethics and dissemination The study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders.This work was supported by the ACT Health Private Practice Fund and Maurice Sando Foundation Sponsorship Scheme 2015 by a local competitive grant process