ORCID Profile
0000-0002-4641-8192
Current Organisations
King's College London
,
Guy's and Saint Thomas' NHS Foundation Trust
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Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.JCRC.2013.06.014
Abstract: The purpose of this study is to describe the effect of levosimendan (without loading dose) on hemodynamics, inotropes/vasopressors, and mortality in acute heart failure (AHF). Patients who received levosimendan for AHF were analyzed. Levosimendan dose, hemodynamic data, inotrope/vasopressor requirements, and fluid balance before commencement, at conclusion of, and 24 hours after levosimendan were collected. Mortality is also reported. Eighty-seven patients were analyzed. The mean levosimendan dose (without loading) was 0.096 μg/kg per minute (±0.014), and mean duration, 26 (±7.2) hours. There was no change in heart rate (start, post, and 24 hours post) (92 [±19], 92 [±26], and 92 [±15]) or mean arterial pressure (69 [±10], 72 [±8], and 72 [±10] mm Hg, respectively). There was a significant reduction in median dobutamine from 7.27 to 0 μg/kg per minute and noradrenaline from 0.20 to 0.1 μg/kg per minute before and 24 hours after. There was a significant increase in both mean cardiac index from 2.38 ± 0.0.72 to 2.98 ± 0.0.77 L/min per square meter and in markers of perfusion: base excess from -2.77 to 0.39 mmol/L, and lactate from 2.1 to 1.4 mmol/L before and 24 hours after infusion. Survival was 53%. Levosimendan, without a loading dose, improved cardiac index and perfusion while allowing a reduction in inotropic/vasopressor requirements in patients with AHF.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 17-07-2020
Publisher: Springer Science and Business Media LLC
Date: 19-09-2012
Publisher: SAGE Publications
Date: 05-2020
Abstract: With ongoing progress of components of extracorporeal membrane oxygenation including improvements of oxygenators, pumps, and coating materials, extracorporeal membrane oxygenation became increasingly accepted in the clinical practice. A suitable testing in an adequate setup is essential for the development of new technical aspects. Relevant tests can be conducted in ex vivo models specifically designed to test certain aspects. Different setups have been used in the past for specific research questions. We conducted a systematic literature review of ex vivo models of extracorporeal membrane oxygenation components. MEDLINE and Embase were searched between January 1996 and October 2017. The inclusion criteria were ex vivo models including features of extracorporeal membrane oxygenation technology. The exclusion criteria were clinical studies, abstracts, studies in which the model of extracorporeal membrane oxygenation has been reported previously, and studies not reporting on extracorporeal membrane oxygenation components. A total of 50 studies reporting on different ex vivo extracorporeal membrane oxygenation models have been identified from the literature search. Models have been grouped according to the specific research question they were designed to test for. The groups are focused on oxygenator performance, pump performance, hemostasis, and pharmacokinetics. Pre-clinical testing including use of ex vivo models is an important step in the development and improvement of extracorporeal membrane oxygenation components and materials. Furthermore, ex vivo models offer valuable insights for clinicians to better understand the consequences of choice of components, setup, and management of an extracorporeal membrane oxygenation circuit in any given condition. There is a need to standardize the reporting of pre-clinical studies in this area and to develop best practice in their design.
Publisher: American Medical Association (AMA)
Date: 09-2012
DOI: 10.1001/ARCHPEDIATRICS.2012.41
Abstract: OBJECTIVE To evaluate the impact of a 12-month multicomponent school-based obesity prevention program, Nutrition and Enjoyable Activity for Teen Girls among adolescent girls. DESIGN Group randomized controlled trial with 12-month follow-up. SETTING Twelve secondary schools in low-income communities in the Hunter and Central Coast regions of New South Wales, Australia. PARTICIPANTS Three hundred fifty-seven adolescent girls aged 12 to 14 years. INTERVENTION A multicomponent school-based intervention program tailored for adolescent girls. The intervention was based on social cognitive theory and included teacher professional development, enhanced school sport sessions, interactive seminars, nutrition workshops, lunch-time physical activity sessions, handbooks and pedometers for self-monitoring, parent newsletters, and text messaging for social support. MAIN OUTCOME MEASURES Body mass index (BMI, calculated as weight in kilograms ided by height in meters squared), BMI z score, body fat percentage, physical activity, screen time, dietary intake, and self-esteem. RESULTS After 12 months, changes in BMI (adjusted mean difference, -0.19 95% CI, -0.70 to 0.33), BMI z score (mean, -0.08 95% CI, -0.20 to 0.04), and body fat percentage (mean, -1.09 95% CI, -2.88 to 0.70) were in favor of the intervention, but they were not statistically different from those in the control group. Changes in screen time were statistically significant (mean, -30.67 min/d 95% CI, -62.43 to -1.06), but there were no group by time effects for physical activity, dietary behavior, or self-esteem. CONCLUSIONS A school-based intervention tailored for adolescent girls from schools located in low-income communities did not significantly reduce BMI gain. However, changes in body composition were of a magnitude similar to previous studies and may be associated with clinically important health outcomes. TRIAL REGISTRATION anzctr.org.au Identifier: 12610000330044.
Publisher: SAGE Publications
Date: 14-12-2020
Abstract: During the Coronavirus Disease 2019 (COVID-19) pandemic institutions have needed to develop pragmatic clinical pathways to balance the excess critical care demand and local resources. In this single-centre retrospective cohort study we describe the outcomes of COVID-19 patients admitted to Guy’s and St. Thomas’ NHS Foundation Trust (GSTT) critical care service. Patients were managed according to a local respiratory failure management pathway that was predicated on timely invasive ventilation when indicated and tailored ventilatory strategies according to pulmonary mechanics. Between 2 March and 25 May 2020 GSTT critical care service admitted 316 patients with confirmed COVID-19. Of the 201 patients admitted directly through the Emergency Department (ED) with a completed critical care outcome, 71.1% survived to critical care discharge. These favourable outcomes may serve to inform the wider debate on optimal organ support in COVID-19.
Publisher: Elsevier BV
Date: 03-2004
DOI: 10.1093/BJA/AEH519
Publisher: Springer Science and Business Media LLC
Date: 30-07-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 18-04-2023
DOI: 10.1161/CIRCULATIONAHA.122.062371
Abstract: Venoarterial extracorporeal membrane oxygenation provides cardiorespiratory support to patients in cardiogenic shock. This comes at the cost of increased left ventricle (LV) afterload that can be partly ascribed to retrograde aortic flow, causing LV distension, and leads to complications including cardiac thrombi, arrhythmias, and pulmonary edema. LV unloading can be achieved by using an additional circulatory support device to mitigate the adverse effects of mechanical overload that may increase the likelihood of myocardial recovery. Observational data suggest that these strategies may improve outcomes, but in whom, when, and how LV unloading should be employed is unclear all techniques require balancing presumed benefits against known risks of device-related complications. This review summarizes the current evidence related to LV unloading with venoarterial extracorporeal membrane oxygenation.
Publisher: SAGE Publications
Date: 14-10-2022
DOI: 10.1177/02676591221133657
Abstract: Extracorporeal membrane oxygenation (ECMO) continues to play an essential role in organ support in cardiogenic shock or acute respiratory distress syndrome and bridging to transplantation. The main purpose of the present survey was to define which clinical and organizational practices are adopted for the administration of physiotherapy in adult patients undergoing ECMO support worldwide. This international survey was conceived in November 2021. The survey launch was announced at the 10th EuroELSO (European ELSO chapter) Congress, London, May 2022. The survey returned 32 questionnaires from 29 centers across 14 countries. 17 centers (53.1%) had more than 30 intensive care unit beds available and most (46.8%) were able to care for five to 10 patients on extracorporeal life support simultaneously. The predominant physiotherapist-to-patient ratio was 1: (37.5%) physiotherapy was available 5/7 days and 7/7 days by 31.2% and 25% respectively. Respiratory physiotherapy was not defined by a specific protocol in most centers (46.8%) while 31.2% declared that the treatment commences less than 12 h after sedation is stopped/reduced. Mostly, early physiotherapy in non-cooperative ventilated patients was provided within the first 48 h (68.6%) and consisted of as passive range of motion, in-bed positioning, and splinting. Postural passages and sitting were provided to patients and walking was included in those advanced motor activities which are part of the treatment. Physiotherapy in patients on ECLS is feasible, however substantial variability exists between centers with a trend of delivering not protocolized and understaffed rehabilitation practices.
Publisher: Elsevier BV
Date: 03-2023
Publisher: SAGE Publications
Date: 23-08-2019
Abstract: Extracorporeal gas exchange requires the passage of oxygen and carbon dioxide (CO 2 ) across an artificial membrane. Current European Union regulations do not require the transfer to be assessed in models using clinically relevant haemoglobin, making it difficult for clinicians to understand the CO 2 clearance of a membrane, and how it changes in relation to sweep gas flow through the membrane. The characteristics of membrane CO 2 clearance are described using a single membrane at different sweep gas flows in an in vitro model with clinically relevant haemoglobin concentrations using three separate methods of calculating CO 2 clearance. To define the CO 2 removal characteristics of the extra-corporeal CO 2 removal (ECCO 2 R) device, we devised an in-vitro gas exchange circuit formed by a dedicated ECCO 2 R circuit (ALung, Pittsburgh, USA) in series with two membrane oxygenators. The system was primed with donated expired human red cells provided by the local blood bank. The experimental set-up allowed constant CO 2 input (via one membrane oxygenator) with variable removal from a portion of the blood in a manner which was analogous to that seen in vivo. Blood gases were measured from different ports in the circuit in order to measure the experimental membrane CO 2 clearance (VCO 2 ). Results demonstrate that the relationship between VCO 2 and gas flow at a constant blood flow of 0.4 L/minute with a haemoglobin of 7 g/dL increases sharply from a gas flow of 0 to 2 L/min but plateaus at gas flows L/minute. VCO 2 , calculated using three different methods, showed a strong linear correlation with minimal bias. The CO 2 clearance of the membrane used in this bench test is non-linear. This has implications for clinical practice, especially during the weaning phase of the device.
Publisher: Elsevier BV
Date: 03-1999
DOI: 10.1016/S0926-6410(98)00047-0
Abstract: A set of five tasks was designed to examine dynamic aspects of visual attention: selective attention to color, selective attention to pattern, iding and switching attention between color and pattern, and selective attention to pattern with changing target. These varieties of visual attention were examined using the same set of stimuli under different instruction sets thus differences between tasks cannot be attributed to differences in the perceptual features of the stimuli. ERP data are presented for each of these tasks. A within-task analysis of different stimulus types varying in similarity to the attended target feature revealed that an early frontal selection positivity (FSP) was evident in selective attention tasks, regardless of whether color was the attended feature. The scalp distribution of a later posterior selection negativity (SN) was affected by whether the attended feature was color or pattern. The SN was largely unaffected by iding attention across color and pattern. A large widespread positivity was evident in most conditions, consisting of at least three subcomponents which were differentially affected by the attention conditions. These findings are discussed in relation to prior research and the time course of visual attention processes in the brain.
Publisher: Elsevier BV
Date: 02-2010
Publisher: Wiley
Date: 06-2001
DOI: 10.1002/HBM.1034
Publisher: Elsevier BV
Date: 05-2021
Publisher: Elsevier BV
Date: 12-2003
DOI: 10.1093/BJA/AEG265
Abstract: The present case report describes the observed sequelae following an inadvertent intrathecal injection of tramadol in a patient with metastatic malignancy. The contributing circumstances before the injection are discussed, as is the potential aetiology of the observed sequelae.
Publisher: SAGE Publications
Date: 11-01-2020
Abstract: Veno-venous extracorporeal carbon dioxide removal allows clearance of CO 2 from the blood and is becoming popular to enhance protective mechanical ventilation and assist in the management of acute exacerbations of chronic obstructive pulmonary disease, including the prevention of intubation. The main factor determining CO 2 transfer across a membrane lung for any given blood flow rate and venous CO 2 content is the sweep gas flow rate. The in vivo characteristics of CO 2 clearance using ultra-low blood flow devices in patients with acute exacerbations of chronic obstructive pulmonary disease has not been previously described. Patients commenced on extracorporeal carbon dioxide removal for acute exacerbations of chronic obstructive pulmonary disease recruited to a randomized controlled trial of non-invasive ventilation versus extracorporeal carbon dioxide removal had pre- and post-membrane circuit gases measured after each increment of sweep gas flow to allow calculation of the transmembrane CO 2 clearance. This was compared with the clearance reported by the device and also corrected to inlet PCO 2 to allow characterization of the CO 2 clearance of the device at different sweep gas flow rates. CO 2 clearance was calculated using both the transmembrane CO 2 whole-blood content difference and CO 2 clearance reported by the device. The two methods demonstrated a linear relationship and agreement with a bias of 14 mL/minute (SD = ±10) and an R 2 of 0.92. The membrane CO 2 clearance was non-linear with nearly two thirds of total clearance achieved with sweep gas flow below 2 L/minute (VCO 2 of 40 ± 16.7 mL/minute) and a plateau above 5 L/minute sweep gas flow (VCO 2 64 ± 1 2.4 mL/minute). The extracorporeal carbon dioxide removal device used in the study provides efficient clearance of CO 2 at low sweep flow rates which then plateaus. This has implications for how the device may be used in clinical practice, particularly during the weaning phase where the final discontinuation of the device may take longer than anticipated. (ClinicalTrials.gov: NCT02086084, registered 13 March 2014, t2/show/NCT02086084 )
Publisher: SAGE Publications
Date: 22-08-2023
Publisher: SAGE Publications
Date: 22-09-2022
DOI: 10.1177/02676591211042563
Abstract: Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children. To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines. The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe. Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS ( n = 88, 66.2%), electroencephalography ( n = 52, 39.1%), transcranial Doppler ( n = 38, 28.5%) and brain injury biomarkers ( n = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority ( n = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors. This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.
Publisher: Wiley
Date: 08-2006
DOI: 10.1111/J.1365-2044.2006.04742.X
Abstract: Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of transfusion of blood and blood components. TRALI is under-diagnosed and under-reported because of a lack of awareness. A number of models have been proposed to explain the pathogenesis of TRALI: an antibody mediated model a two-event biologically active mediator model and a combined model. TRALI can occur with any type of blood product and can occur with as little as one unit. Its presentation is similar to other forms of acute lung injury and management is predominantly supportive. The main strategy in combating TRALI is prevention both through manipulation of the donor pool and through clinical strategies directed at reducing transfusion of blood products including, but not limited to, evidence-based lower transfusion thresholds. This article presents a review of TRALI and addresses the definition, pathology, pathogenesis, clinical manifestations, treatment and prevention of the syndrome.
Publisher: Springer Science and Business Media LLC
Date: 21-04-2022
DOI: 10.1186/S13613-022-01006-8
Abstract: Patients presenting with acute hypercapnic respiratory failure due to exacerbations of chronic obstructive pulmonary disease (AECOPD) are typically managed with non-invasive ventilation (NIV). The impact of low-flow extracorporeal carbon dioxide removal (ECCO 2 R) on outcome in these patients has not been explored in randomised trials. Open-label randomised trial comparing NIV (NIV arm) with ECCO 2 R (ECCO 2 R arm) in patients with AECOPD at high risk of NIV failure (pH 7.30 after ≥ 1 h of NIV). The primary endpoint was time to cessation of NIV. Secondary outcomes included device tolerance and complications, changes in arterial blood gases, hospital survival. Eighteen patients (median age 67.5, IQR (61.5–71) years median GOLD stage 3 were enrolled (nine in each arm). Time to NIV discontinuation was shorter with ECCO 2 R (7:00 (6:18–8:30) vs 24:30 (18:15–49:45) h, p = 0.004). Arterial pH was higher with ECCO 2 R at 4 h post-randomisation (7.35 (7.31–7.37) vs 7.25 (7.21–7.26), p 0.001). Partial pressure of arterial CO 2 (PaCO 2 ) was significantly lower with ECCO 2 R at 4 h (6.8 (6.2–7.15) vs 8.3 (7.74–9.3) kPa p = 0.024). Dyspnoea and comfort both rapidly improved with commencement of ECCO 2 R. There were no severe or life-threatening complications in the study population. There were no episodes of major bleeding or red blood cell transfusion in either group. ICU and hospital length of stay were longer with ECCO 2 R, and there was no difference in 90-day mortality or functional outcomes at follow-up. There is evidence of benefit associated with ECCO 2 R with time to improvement in respiratory acidosis, in respiratory physiology and an immediate improvement in patient comfort and dyspnoea with commencement of ECCO 2 R. In addition, there was minimal clinically significant adverse events associated with ECCO 2 R use in patients with AECOPD at risk of failing or not tolerating NIV. However, the ICU and hospital lengths of stay were longer in the ECCO 2 R for similar outcomes. Trial registration The trial is prospectively registered on ClinicalTrials.gov: NCT02086084. Registered on 13th March 2014, t2/show/NCT02086084?cond=ecco2r& draw=2& rank=8
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1093/BJA/AES161
Publisher: Oxford University Press (OUP)
Date: 09-01-2012
DOI: 10.1093/NDT/GFR707
Abstract: Despite the frequent use of renal replacement therapy (RRT) for patients with acute kidney injury (AKI) in the intensive care unit (ICU), there is no accepted consensus on the optimal indications and timing. The aim of this paper is to identify optimal triggers for RRT in critically ill patients with AKI. We examined data from 2 randomized controlled trials, 2 prospective studies and 13 retrospective trials and found large variation in the different parameters and cut-offs for initiation of RRT. No single biochemical parameter was adequate to define the optimal indication and time to commence RRT. Degree of fluid overload, oliguria and associated non-renal organ failure appeared to be more appropriate parameters for initiation of RRT. We propose a clinical algorithm based on regular assessment of the patient's condition and trends in these parameters. It is intended to aid the process of deciding when to start RRT in critically ill adult patients with AKI. Available evidence suggests that the decision when to start RRT in critically ill patients with AKI should be based on trends in the patient's severity of illness, presence of oliguria and fluid overload and associated non-renal organ failure rather than specific serum creatinine or urea values.
Publisher: Elsevier BV
Date: 10-2008
DOI: 10.1016/J.BPOBGYN.2008.06.008
Abstract: The present chapter considers the evolving role of critical care outreach in the general hospital setting and applied to obstetric patients, the mechanics of transferring critically ill obstetric patients to critical care and radiology areas, the scoring systems in use in critical care, and the difficulties in applying these scoring systems to obstetric patients.
Publisher: Elsevier BV
Date: 10-2010
DOI: 10.1016/J.IJOA.2010.06.005
Abstract: When monitoring postoperative urine output there is no guidance specific to obstetrics. Factors such as peri-operative oxytocin infusions add further complexity. Our aim was to determine a normal range for urine output after elective caesarean section under neuraxial anaesthesia. Sixty women were recruited and for 24h from the time of urethral catheterisation, we recorded urine output and fluid input. We also measured intra-operative blood loss, use of prophylactic oxytocin infusion and markers of renal function. Data were compared with Mann-Whitney U-tests or paired t tests. Oxytocin infusions were used in 45 women (75%). Median (95% CI) urine output in the first 6h was 0.8 (0.4-1.9) mL kg(-1)h(-1) in women receiving oxytocin compared to 1.4 (0.7-2.2)mL kg(-1)h(-1) in those who did not (P=0.02). Urine output for all women at 12 and 18 h was 2.0 (0.7-5.7) and 1.9 (0.5-4.5)mL kg(-1)h(-1). Blood loss was 0.4 (0.2-0.8)L in women with oxytocin infusions and 0.3 (0.1-0.4)L in those without (P=0.003). Mean (SD) pre- and postoperative urine osmolality was 622.5 (185.7) and 293.0 (135.1) mosm/kg, respectively (P<0.0001). Urine output varied widely between subjects, especially after the first 6h and was further reduced by the use of oxytocin infusion. This may have been a direct effect or related to increased blood loss in this group. Oxytocin use should be accounted for when setting a minimum postoperative urine output. We also found high pre-operative urine osmolalities suggesting significant dehydration.
Publisher: SAGE Publications
Date: 20-04-2023
DOI: 10.1177/02676591231157273
Abstract: Introduction: Simulation training offers an authentic team-based learning opportunity without risk to real patients. The Educational Corner at the annual congress of the European Branch of Extracorporeal Life Support Organisation (EuroELSO) provided an opportunity for multiple simulation training sessions facilitated by experts from all over the world. Aim: We aimed to review the educational impact of EuroELSO Educational Corner and whether it provides a quality ECLS training to a wide spectrum of multidisciplinary international attendees utilising high and low fidelity simulation, workshops and hands on sessions. Methods: During the congress, 43 sessions were conducted dedicated to ECLS education with identified educational objectives. The sessions focused on management of adults and children on V-V or V-A ECMO. Adult sessions covered emergencies on mechanical circulatory support with management of LVAD and Impella, managing refractory hypoxemia on V-V ECMO, emergencies on ECMO, renal replacement therapy on ECMO, V-V ECMO, ECPR cannulation and performing perfect simulation. Paediatric sessions covered ECPR neck and central cannulation, renal replacement on ECMO, troubleshooting, cannulation workshop, V-V recirculation, ECMO for single ventricle, PIMS-TS and CDH, ECMO transport and neurological injury. Results: The Educational Corner was attended by more than 400 participants over the two congress days. Majority of responders (88%) reported that training sessions met the set educational goals and objectives and that this would change their current practice. Almost all (94%) reported that they received useful information and 95% would recommend the session to their colleagues. Conclusion: The Educational Corner, as an integral component of the annual EuroELSO congress, achieved the set educational goals and provided quality education based on the recipient survey. Structured multidisciplinary ECLS education with standardised curriculum and feedback is an important key step in delivering quality training to an international audience. Standardisation of European ECLS education remains an important focus of the EuroELSO.
Publisher: SAGE Publications
Date: 05-06-2020
Abstract: In the last decade, dual-lumen cannulae have been increasingly applied in patients undergoing extracorporeal life support. Well-performing vascular access is crucial for efficient extracorporeal membrane oxygenation support thus, guidance for proper cannulae size is required. Pressure–flow charts provided by manufacturers are often based on tests performed using water, rarely blood. However, blood is a shear-thinning and viscoelastic fluid characterized by different flow properties than water. We performed a study evaluating pressure–flow curves during standardized conditions using human whole blood in two commonly available dual-lumen cannulae used in neonates, pediatric, and adult patients. Results were merged and compared with the manufacturer’s corresponding curves obtained from the public domain. The results showed that using blood as compared with water predominantly influenced drainage flow. A 10-80% higher pressure-drop was needed to obtain same drainage flow (hematocrit of 26%) compared with manufacturer’s water charts in 13-31 Fr bi-caval dual-lumen cannulae. The same net difference was found in cavo-atrial cannulae (16-32 Fr), where a lower drainage pressure was required (Hct of 26%) compared with the manufacturer’s test using blood with an Hct of 33%. Return pressure–flow data were similar, independent whether pumping blood or water, to the data reported by manufacturers. Non-standardized testing of pressure–flow properties of extracorporeal membrane oxygenation dual-lumen cannulae prevents an adequate prediction of pressure–flow results when these cannulae are used in patients. Properties of dual-lumen cannulae may vary between sizes within same cannula family, in particular concerning the drainage flow.
Publisher: SAGE Publications
Date: 12-07-2019
Abstract: In November 2016, our institution switched from alfentanil to fentanyl for analgesia and sedation in adult patients receiving extracorporeal membrane oxygenation. There is no published evidence comparing the use of alfentanil with fentanyl for sedation in extracorporeal membrane oxygenation patients. We conducted a retrospective observational study to explore any significant differences in patient outcomes or in the prescribing of adjunct sedatives before and after the switch. Patients were retrospectively identified from a prospectively recorded database of all patients who received extracorporeal membrane oxygenation at our institution between January 2016 and October 2017. Patients included those sedated with alfentanil or fentanyl. The total daily doses of intravenous opioids (alfentanil or fentanyl) were calculated for each patient, and the prescribing of adjunctive sedative or analgesic agents was recorded. Patient demographics, extracorporeal membrane oxygenation modality, clinical outcomes including mortality and length of intensive care and hospital stay were recorded. A total of 174 patients were identified, 69 on alfentanil and 95 on fentanyl. There was no difference found between groups for mode of extracorporeal membrane oxygenation, age, Acute Physiology and Chronic Health Evaluation 2 score (APACHE II) and Charlson score, except for body mass index (p = 0.002). No differences in patient outcomes was observed between groups, although patients in the alfentanil group received a significantly higher median total daily dose of adjuvant sedatives (quetiapine (p = 0.016) and midazolam (p = 0.009)). No differences in patient outcomes were found between extracorporeal membrane oxygenation patients sedated with alfentanil compared with fentanyl. There was a statistically significant reduction in some adjunctive sedatives in patients managed with a fentanyl-based regimen. Prospective studies are required to confirm these results.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 26-02-2021
DOI: 10.1097/MAT.0000000000001422
Abstract: This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients ( %) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19–related ECMO should be used however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19–related ARDS, myocarditis, or multisystem inflammatory syndrome in children (MIS-C) conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
Publisher: American Psychological Association (APA)
Date: 08-1998
Publisher: SAGE Publications
Date: 05-09-2020
Abstract: An overview of the current system for referrals and management of severe respiratory failure in the United Kingdom. We outline the history of severe respiratory failure centres, the process of retrieving a patient for veno-venous extra corporeal membrane oxygenation and highlight some common difficulties and pitfalls when referring these critically unwell patients
Publisher: Elsevier BV
Date: 02-2010
Publisher: Oxford University Press (OUP)
Date: 02-05-2012
DOI: 10.1111/J.2042-7174.2012.00205.X
Abstract: Significant errors can be made during medication prescribing, dispensing and administration. One source of error and potential for harm is unintentional omission. Medicines reconciliation seeks to reduce the impact of this between transfer of care. In long-term hypothyroidism, patients are dependent upon levothyroxine and there are few contraindications to its prescription. We considered levothyroxine prescription in long-term hypothyroidism as a marker of medicines reconciliation on admission and during stay in the intensive care unit (ICU). A retrospective chart review was undertaken in a tertiary referral university ICU with all patients who were receiving long-term levothyroxine therapy identified. Notes were reviewed for the presence of thyroid-replacement prescription and for thyroid function tests, in addition to demographic, length of stay and mortality data. Thyroid-replacement therapy was not prescribed for more than 7 days in 23/133 (17.3%) patients and omitted entirely in three patients. A further 28/133 (21.1%) patients were intolerant of enteral feeding for more than 7 days and were thus unable to have oral levothyroxine administered. None of these patients received parenteral therapy. Thyroid function tests were performed in 104/133 (78.2%) patients. Prescription of chronic therapy, in this case thyroid-replacement therapy, was inadequate. This highlights the need for a progressive medicines-reconciliation process embedded within the daily ICU programme.
Publisher: Cold Spring Harbor Laboratory
Date: 03-12-2020
DOI: 10.1101/2020.11.26.20229989
Abstract: Clinical metagenomics (CMg) is being evaluated for translation from a research tool into routine diagnostic service, but its potential to significantly improve management of acutely unwell patients has not been demonstrated. The SARS-CoV-2 pandemic provides impetus to determine that benefit given increased risk of secondary infection and nosocomial transmission by multi-drug resistant (MDR) pathogens linked with expansion of critical care capacity. Prospective evaluation of CMg using nanopore sequencing was performed on 43 respiratory s les over 14 weeks from a cohort of 274 intubated patients across seven COVID-19 intensive care units. Bacteria or fungi were cultured from 200 (73%) patients, with a predominance of Klebsiella spp . (31%) and C. striatum (7%) amongst other common respiratory pathogens. An 8 hour CMg workflow was 93% sensitive and 81% specific for bacterial identification compared to culture, and reported presence or absence of β-lactam resistance genes carried by Enterobacterales that would modify initial guideline-recommended antibiotics in every case. CMg was also 100% concordant with quantitative PCR for detecting Aspergillus fumigatus (4 positive and 39 negative s les). Single nucleotide polymorphism (SNP)-typing using 24 hour sequence data identified an MDR- K. pneumoniae ST307 outbreak involving 4 patients and an MDR- C. striatum outbreak potentially involving 14 patients across three ICUs. CMg testing for ICU patients provides same-day pathogen detection and antibiotic resistance prediction that significantly improves initial treatment of nosocomial pneumonia and rapidly detects unsuspected outbreaks of MDR-pathogens.
Publisher: Springer Science and Business Media LLC
Date: 2011
DOI: 10.1186/CC10294
Publisher: SAGE Publications
Date: 05-2020
Abstract: Introduction: Simulation-based learning and hands-on learning are popular in medicine, particularly in areas where life-saving manoeuvres and team skills are required. Simulations can be provided in different environments: directly in hospitals (in situ), in dedicated facilities (simulation rooms) or, on occasion, at scientific meetings, thus taking advantage of the delegates’ motivation. Simulation-based learning in extracorporeal life support is also increasingly relevant due to the inherent features of the often difficult and emergent decision-making, approaches and management involved, as well as to the challenging multidisciplinary teamwork. Aim: Based on these premises and on the constant rise in interest in starting new extracorporeal life support programmes, the EuroELSO organization has, since the beginning of its scientific activities, established an ‘ad hoc’ space (Educational Corner) for training and hands-on sessions with a limited number of attendees per session during its annual congress. Methods: Experienced trainers deliver repeated dedicated sessions on fundamental aspects of extracorporeal life support management. After several years of sessions, a questionnaire was prepared and delivered to the attendees at the 8th annual congress in Barcelona. Results: More than 90% of the responders indicated that they would recommend the workshop to their colleagues and that they received useful information during the workshops. Over 85% of the responders (85-97%) indicated that the workshops met the set educational goals and objectives and indicated that the simulation sessions would have a positive impact on their daily practice. Conclusion: The Educational Corner during the EuroELSO Congress has achieved great popularity, as shown by the number of attendees participating each year, and presumably improves many technical and behavioural skills among the attendees.
Publisher: Informa UK Limited
Date: 02-11-2019
DOI: 10.1080/15412555.2019.1681390
Abstract: The assessment of the work of breathing (WOB) of patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) is difficult, particularly when the patient first presents with acute hypercapnia and respiratory acidosis. Acute exacerbations of COPD patients are in significant respiratory distress and noninvasive measurements of WOB are easier for the patient to tolerate. Given the interest in using alternative therapies to noninvasive ventilation, such as high flow nasal oxygen therapy or extracorporeal carbon dioxide removal, understanding the physiological changes are key and this includes assessment of WOB. This narrative review considers the role of three different methods of assessing WOB in patients with acute exacerbations of COPD. Esophageal pressure is a very well validated measure of WOB, however the ability of patients with acute exacerbations of COPD to tolerate esophageal tubes is poor. Noninvasive alternative measurements include parasternal electromyography (EMG) and electrical impedance tomography (EIT). EMG is easily applied and is a well validated measure of neural drive but is more likely to be degraded by the electrical environment in intensive care or high dependency. EIT is less well validated as a tool for WOB in COPD but extremely well tolerated by patients. Each of the different methods assess WOB in a different way and have different advantages and disadvantages. For research into therapies treating acute exacerbations of COPD, combinations of EIT, EMG and esophageal pressure are likely to be better than only one of these.
Publisher: SAGE Publications
Date: 10-01-2023
DOI: 10.1177/02676591221151034
Abstract: An analysis on the ECLS use for patients with respiratory or cardiac support in COVID-19 based on an international response to EuroELSO survey, aims to generate a more comprehensive understanding of ECLS role during the recent viral pandemic. EuroELSO announced the survey at the 10th annual congress in London, May 2022. The survey covered 26 multiple-choice questions. The survey returned 69 questionnaires from 62 centers across 22 European countries and seven centers across five non-European countries. Most of the centers providing ECLS for COVID-19 patients had more than 30 runs for respiratory support since December 2019. In the same period, at least 31 runs in adult COVID-19 patients have been performed in 48 of 69 centers (69.6%). The reported pediatric data from 18 centers is limited to less than the patients per center. Majority of the COVID-19 patients received respiratory ECLS support and adult patients dominated. The indications and contraindications are broadly aligned with available guidelines. Most of the centers considered age or biological age as a relative or absolute contraindication for ECLS in COVID-19. ECLS withdrawal criteria in COVID-19 are controversial because the long-term outcomes after ECLS in COVID-19 and the impact of critical illness and the impact of long-COVID are still not known.
Publisher: Elsevier BV
Date: 06-2003
DOI: 10.1016/S0926-6410(02)00246-X
Abstract: This combined PET and ERP study was designed to identify the brain regions activated in switching and ided attention between different features of a single object using matched sensory stimuli and motor response. The ERP data have previously been reported in this journal [64]. We now present the corresponding PET data. We identified partially overlapping neural networks with paradigms requiring the switching or iding of attention between the elements of complex visual stimuli. Regions of activation were found in the prefrontal and temporal cortices and cerebellum. Each task resulted in different prefrontal cortical regions of activation lending support to the functional subspecialisation of the prefrontal and temporal cortices being based on the cognitive operations required rather than the stimuli themselves.
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.AMEPRE.2013.04.014
Abstract: Obesity prevention among youth of low SES is a public health priority given the higher prevalence of youth obesity in this population subgroup. To evaluate the 24-month impact of a school-based obesity prevention program among adolescent girls living in low-income communities. The study was a school-based group RCT, the Nutrition and Enjoyable Activity for Teen Girls (NEAT Girls) intervention. The study involved 12 secondary schools located in low-income communities in New South Wales, Australia. Participants were 357 adolescent girls (aged 13.2 ± 0.5 years). The 12-month multicomponent intervention was guided by social cognitive theory and involved strategies to promote physical activity, reduce sedentary behaviors, and improve dietary outcomes. The primary outcome was BMI, and secondary outcomes were BMI z-score percentage body fat (bioelectrical impedance analysis) physical activity (accelerometers) dietary intake and recreational screen-time (self-report). Data were collected in 2010-2012 and analyzed in 2012. After 24 months, there were no intervention effects on BMI (adjusted mean difference -0.33, 95% CI= -0.97, 0.28, p=0.353) and BMI z-score (-0.12, 95% CI= -0.27, 0.04, p=0.178). However, there was a group-by-time interaction for percentage body fat (-1.96%, 95% CI= -3.02, -0.89, p=0.006). Intervention effects for physical activity, screen time, and dietary intake were not significant. The NEAT Girls intervention did not result in effects on the primary outcome. Further study of youth who are "at risk" of obesity should focus on strategies to improve retention and adherence in prevention programs. This study is registered at Australian New Zealand Clinical Trials ACTRN1261000033004.
Publisher: SAGE Publications
Date: 05-2020
Abstract: The criteria and process for liberation from extracorporeal membrane oxygenation in patients with severe acute respiratory distress syndrome are not standardized. The predictive accuracy of the oxygen challenge test as a diagnostic test in determining weaning and decannulation from venovenous extracorporeal membrane oxygenation was tested. A single-centre, retrospective, observational cohort study. Tertiary referral severe respiratory failure centre in a university hospital in the United Kingdom. 253 adults with severe acute respiratory distress syndrome requiring extracorporeal membrane oxygenation. None Patients had median age: 43 years (interquartile range: 32-52) years, extracorporeal membrane oxygenation days: 9 (interquartile range: 6-14) and acute physiology and chronic health evaluation II score 17.5 (interquartile range: 15-20). Oxygen challenge test value (PaO 2-OCT ) with best prediction was 31 kPa (232 mmHg sensitivity 0.74 specificity 0.70 area under curve 0.77 (confidence interval: 0.73-0.81)). PaO 2-OCT did not perform well as a prospective test to identify readiness to decannulation. Only 24 patients (10%) were decannulated 48 hours after their first positive oxygen challenge test (true positive) and 73.4% patients were false positives (positive oxygen challenge test but not decannulated). True positives had higher tidal volume (541 ± 218 vs 368 mL ± 210 p 0.05) and minute ventilation (9.34 ± 5.36 vs 6.33 L/min ± 4.43 p 0.05). Blood flow (3.17 ± 0.23 vs 3.53 L/min ± 0.56 p 0.05), sweep gas flow (1.42 ±1.83 vs 3.74 L/min ± 2.43 p 0.05) and extracorporeal membrane oxygenation minute volume at time of first positive oxygen challenge test was lower in true positives (1.66 ± 2.26 vs 4.82 ± 3.43 L/min). This was a strong predictor for decannulation within 48 hours (area under curve: 0.88, confidence interval: 0.88-0.89). In severe acute respiratory distress syndrome requiring venovenous extracorporeal membrane oxygenation, the PaO 2-OCT is a poor predictor of readiness to decannulate from extracorporeal membrane oxygenation. Additional factors involved in the control of respiratory drive and carbon dioxide clearance, particularly native lung dead space and total minute ventilation, should be assessed.
Publisher: SAGE Publications
Date: 05-2020
Abstract: The substantial increase in the number of patients receiving extracorporeal membrane oxygenation over the last decade has led to an evolution of indications and an expansion into wider patient groups. One of the unanticipated benefits of the increase in extracorporeal membrane oxygenation has been a change in the understanding of the natural history of many respiratory diseases. Development in technology and materials, reduced extracorporeal membrane oxygenation–specific complications, and improvement of critical care, in general, have facilitated longer extracorporeal membrane oxygenation runs, and the definition of prolonged extracorporeal membrane oxygenation was recently expanded to continuous support for more than 28 days. This survey aimed to describe European ECMO centers’ perception and arbitrary definition of prolonged extracorporeal membrane oxygenation, patient management, and futility. Of 94 center responses, 37% regarded 14-21 days, 30% 21-28 days, and 28% days as prolonged treatment. Bridge to recovery (64%) or to transplantation (20%) was the most common causes. Awake, and ambulation while on extracorporeal membrane oxygenation was reported from 34% of the centers. In case of perceived futility, decision to withdraw was taken in 65% of the centers in agreement between profession and family and in 30% by profession only. One-fourth of the centers did not discontinue support. Large differences prevail among European ECMO centers concerning local perception and patient management in prolonged extracorporeal membrane oxygenation.
Publisher: SAGE Publications
Date: 06-2020
Abstract: The variability of acute respiratory distress syndrome management may affect the referral practice to severe respiratory failure centres. We described the management of acute respiratory distress syndrome in our catchment area. An electronic survey was administered to 42 intensive care units in South-East England. Response rate was 71.4%. High-flow nasal oxygen and non-invasive ventilation were used ‘often’ in moderate-acute respiratory distress syndrome by 46.7% and 60%. During invasive ventilation, 90% preferred pressure control, targeting tidal volumes of 6–8 ml/kg (53.3%) or 4–6 ml/kg (46.7%). Positive end-expiratory pressure was selected by positive end-expiratory pressure/inspiratory fraction of oxygen tables (50%) or decremental positive end-expiratory pressure trials (20%). Neuro-muscular blockers were widely used, although routinely by only 3.3%. High-frequency oscillatory ventilation (10%) and inhaled nitric oxide (13.3%) were rarely used. None used oesophageal manometry. Recruitment manoeuvres were used ‘often’ by 26.7%. Equipment (90%) and protocols (80%) for prone position were common, with sessions mostly lasting 12–18 h. Although variable, practice well reflected the available evidence. Proning was widely practiced with good availability of educational resources and protocolised care.
Publisher: BMJ
Date: 20-07-2011
Publisher: Elsevier BV
Date: 07-2021
DOI: 10.1016/J.RMED.2021.106419
Abstract: Cognitive dysfunction is often reported in patients who have experienced acute respiratory distress syndrome (ARDS). Extra Corporeal Membrane Oxygenation (ECMO) therapy is increasingly used to manage ARDS patients in ICU, transforming survival rates. However, few studies have examined cognitive outcomes. We examined self-reported cognitive complaints, psychiatric outcomes and neuropsychological test performance in survivors of severe hypoxaemia managed with VV-ECMO, at 18-24 month follow-up, compared with a group of healthy controls. Over 70% of ECMO-treated patients (N = 46) complained of difficulty in at least one aspect of cognition on self-report measures (study 1). However, a much lower frequency of cognitive impairment was found on formal neuropsychological testing (study 2). Mean neuropsychological test scores of the ECMO group (N = 24) did not significantly differ from healthy controls (N = 23) after controlling for depression. Less than 30% of ECMO-treated patients showed impairments in anterograde memory, and deficits on general IQ or executive function were seen in <17% of patients. However, we observed high levels of self-reported anxiety and depression in the ECMO-treated patients. Cognitive outcomes in ECMO-treated patients were generally good, with preserved neuropsychological function in the majority of patients, despite severe hypoxaemia and high rates of self-reported difficulties. However, we saw high levels of mental health symptoms in these patients, highlighting a need for psychological support.
Location: Australia
Location: Australia
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Nicholas Barrett.