External ventricular drains (EVDs) monitor and manage increased intracranial pressure (ICP) in neurosurgical patients. EVD-related infection (ERI) is a serious complication linked to significant morbidity and mortality. This review aims to determine the overall incidence of ERI, identify key risk factors, compare the effectiveness of different EVD types, and analyze causative organisms. A comprehensive literature search was performed on public databases (PubMed/MEDLINE, Cochrane Library, and Google Scholar) from inception to 15 July 2025. The Newcastle-Ottawa Scale (NOS) tool and Cochrane tool (RoB-2) were used to assess the quality of included studies. A random-effects model was applied for all meta-analyses. The overall incidence of ERI was 8.6% (95% CI 7.2-10.3, I 2 = 93%). The pooled incidence was 4.3% in AI EVDs, compared with 9.4% in plain EVDs and 10.5% in SI EVDs. In subgroup analysis, the overall incidence of ERI in studies conducted in the US was notably lower than that in the non-US countries (4.1% vs 10.4%). In comparison to plain catheters, the use of AI EVDs was associated with significant reduced risk of ERI occurrence (OR = 0.43, 95% CI 0.28-0.67, I 2 = 16%, p < 0.01), but there was no significant difference between AI EVDs over SI catheters (OR = 0.44, 95% CI 0.15-1.29, I 2 = 5%, p = 0.13). In sensitivity analysis, compared to plain EVDs, SI EVDs were associated with a significantly reduced risk of ERI (OR = 0.58, 95% CI 0.38-0.88, I 2 = 0%, p = 0.01). Placement of more than 1 EVD, CSF leakage, and extended catheter duration were significant risk factors for ERI. Our results revealed that ERI was associated with longer duration of EVD, hospital, and ICU length of stay. The majority of infections were due to Gram-positive bacteria (65%). The Staphylococcus (49.8%), followed by Acinetobacter (7.6%), and Klebsiella (7%) species, and at lower classifications, CoNS (58%) were the most common causative organisms. Our findings suggest that AI EVDs are associated with a lower risk of ERI compared with plain EVDs. In contrast, SI EVDs did not show a statistically significant reduction in ERI risk compared with plain EVDs in the primary analysis, although a significant reduction was observed in sensitivity analysis after excluding small studies. Further multicenter randomized controlled trials are necessary to validate these conclusions.
Background:Survivors of critical illness describe delirium as a significant problem. Delirium is multi-factorial in origin and known to be associated with disrupted circadian rhythms. The timing of enteral feeding contributes to circadian rhythms. We hypothesised that the normal practice of providing continuous enteral nutrition during critical illness may contribute to delirium, due to the adverse effects on circadian rhythms. Methods:DAYDREAM is a multicentre, open-label, randomised controlled feasibility trial conducted in two UK ICUs. Forty mechanically ventilated adult patients requiring enteral nutrition will be randomised 1:1 to receive either daytime-only feeding (08:00-22:00) or standard continuous enteral feeding. The primary outcomes are feasibility metrics, including recruitment, retention, intervention fidelity, and completeness of data collection. Secondary outcomes include delirium- and coma-free days (assessed using RASS and CAM-ICU), feeding intolerance, glycaemic control, ICU length of stay, and 90-day mortality. A nested qualitative sub-study will explore staff acceptability and implementation barriers. A mechanistic sub-study will evaluate circadian rhythmicity using physiological and biochemical markers between days 3 and 5 of ICU admission. Results:Recruitment commenced in December 2025, with completion anticipated in 2027. Findings will inform the design and delivery of a subsequent definitive multicentre trial. Conclusion:This study will determine the feasibility of implementing daytime-only enteral feeding in critically ill adults and provide preliminary data on its clinical and circadian effects.
Prevention and management of delirium is important for patients on intensive care units (ICU). National Guidelines recommend visible 24-hour clocks for ICU patients. Multi-modal approaches including improved orientation help prevent delirium, but literature on specific impacts of clocks on orientation in ICU patients is limited. This quality improvement project in a tertiary ICU introduced clocks at each bedspace and assessed impact on patient orientation. Proportion of patients orientated to time improved from 45% initially, to 70% post-implementation, then 94% following clock repositioning. Feedback was positive. Clocks are effective in aiding re-orientation which may support delirium prevention and management in ICUs.
Haemodynamic ultrasound is central to bedside assessment of circulatory failure in critical care. The Focused UltraSound in Intensive Care HaemoDynamics (FUSIC HD) programme was originally designed to provide a structured national framework for physiologically focused ultrasound assessment, distinct from comprehensive diagnostic echocardiography. Since publication of the original framework, experience from training cohorts, logbook review, and centralised summative assessment has shown that a broader range of haemodynamic parameters can be acquired and interpreted in routine practice. This article outlines the rationale, development process, and methodological principles underpinning the recent revision of the FUSIC HD dataset. The updated framework incorporates additional assessment of left ventricular performance, right ventricular function, and pulmonary vascular loading, together with a refined approach to estimating left atrial pressure while maintaining emphasis on physiological coherence, bedside feasibility, and avoidance of unnecessary diagnostic complexity. The aim is not to expand diagnostic echocardiography capability, but to support more integrated haemodynamic interpretation in critically ill patients within an established training and governance structure.
Mechanical ventilation remains a cornerstone of organ support in critically ill patients, yet modern intensive care ventilators incorporate increasingly complex modes and proprietary terminology that can obscure the physiological principles underpinning their use. A clear understanding of these principles is essential to enable safe, individualised, and lung protective ventilation. This article provides the physiological foundation for a four-part educational series on mechanical ventilation in adult critical care. Key concepts including positive end-expiratory pressure, airway pressures, resistance, compliance, elastance, and respiratory time constants are reviewed. Evidence supporting contemporary ventilation strategies is summarised, emphasising the importance of low tidal volume ventilation and individualisation of ventilator settings according to patient physiology. The ventilator breath cycle is described in terms of triggering, delivery, cycling, and expiration, providing a framework that is independent of manufacturer-specific nomenclature. A structured approach to ventilator modes based on control variables, breath sequence, and targeting schemes is presented using the Taxonomic Attribute Grouping system. Conventional pressure- and volume-controlled modes are discussed alongside assisted and mandatory ventilation strategies. Advanced modes, including airway pressure release ventilation and closed-loop systems, are reviewed with reference to their physiological rationale and current evidence base. Mechanical ventilation should be understood as a set of physiological principles rather than a collection of proprietary mode names. By focusing on pressure, flow, volume, timing, and patient-ventilator interaction, clinicians can better adapt ventilatory support to the changing pathophysiology of individual patients. This article aims to provide a practical framework for trainees and clinicians seeking to understand contemporary mechanical ventilation and to support subsequent articles addressing lung-protective ventilation, difficult weaning, and extracorporeal respiratory support.
Background:Early management decisions after intubation, such as humidification strategy or initiation of prevention bundles for ventilator-associated pneumonia, often depend on the expected duration of invasive mechanical ventilation (IMV). However, no simple, standardised method exists to support such estimates at the bedside. We aimed to develop and validate the Length of Ventilation (LoVe) index, a score to predict prolonged IMV beyond 48 h using peri-intubation data. Methods:We conducted a retrospective cohort study using two large, publicly available ICU databases: AmsterdamUMCdb for model development and internal validation, and MIMIC-IV for external validation. The primary outcome was prolonged IMV, defined as support beyond 48 h or death within 48 h. Two LoVe variants were derived: a ventilator-inclusive version incorporating ventilator settings, and a ventilator-agnostic version without ventilator settings. Predictors identified via logistic regression were discretised into clinically interpretable ranges and summed into an additive score. Clinical utility was assessed using decision curve analysis. Results:In the cardiac surgery and non-cardiac surgery cohorts, the ventilator-inclusive LoVe index achieved AUROC scores of 0.82 and 0.75, respectively. The ventilator-agnostic version reached 0.72 in the non-cardiac surgery cohort. Validation in MIMIC-IV yielded 0.71 and 0.68 for the ventilator-inclusive version, and 0.71 and 0.65 for the ventilator-agnostic index. Decision curve analysis demonstrated that both LoVe indices provided meaningful clinical utility. Conclusions:The LoVe index provides a simple, interpretable bedside tool to estimate the likelihood of prolonged IMV early after intubation, showing consistent external validity and potential to support early ICU decision-making.
Background: Appropriate antibiotic use can save life in sepsis while reducing the risk of bacterial resistance. Biomarkers, such as procalcitonin (PCT), can inform the timing of the clinical decision to stop a course of antibiotics. The recently reported multicentre ADAPT-Sepsis trial showed that a daily PCT-guided protocol can safely reduce the duration of antibiotic use in people with suspected sepsis. This linked study aimed to identify potential barriers and facilitators to implementation of PCT testing. Methods: This process evaluation collected qualitative and quantitative data from clinical teams involved in the delivery of adapt-sepsis. Trial site staff were invited to complete a questionnaire and to participate in a semistructured interview. Responses were thematically analysed and compared with constructs from the Consolidated Framework for Implementation Research (CFIR v2.0). Results: A total of 69 staff from 26 critical care units responded to the online questionnaire ( n = 55); the interview invitation ( n = 3); or both ( n = 11). Interviewees included critical care consultants, junior doctors, and research nurses. At least 60% of ADAPT-Sepsis trial staff respondents supported the continuation of PCT testing, even before trial results were publicised. Several of the implementation facilitators related to factors evident at the level of the site/organisation, such as microbiology involvement and increasing access to knowledge and information about evidence supporting the tests. Cost was raised as a potential barrier. Conclusion: Adoption of biomarker tests such as PCT may be facilitated by communicating high-quality evidence, supported by staff focussed on antimicrobial stewardship. Cost implications have been considered in a related economic analysis. Study registration: This study was prospectively registered online. The unique identifying number at researchregistry.com is researchregistry4244.
Introduction: Sepsis poses a substantial global health threat, accounting for approximately 20% of all deaths worldwide. In Australia, available reports indicate a rising incidence, with over 84,000 hospital admissions each year. Although in-hospital survival has improved, many survivors continue to experience long-term physical, psychological, cognitive, and health-related quality-of-life (HRQoL) challenges, collectively known as post-sepsis syndrome (PSS). However, research examining these long-term outcome trajectories remains fragmented and has not been comprehensively synthesised. This scoping review aims to map current evidence, clarify key concepts, and identify gaps in knowledge regarding PSS and related post-sepsis outcomes within the Australian context. Methods: A scoping review was carried out in accordance with the updated methodological framework provided by the Joanna Briggs Institute (JBI). A comprehensive search across multiple databases was conducted, including both peer-reviewed and grey literature. Two reviewers independently screened and extracted data. Narrative thematic analysis was employed to identify key themes and knowledge gaps. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist, and the review protocol was published on the Open Science Framework (OSF): https://doi.org/10.17605/osf.io/xhzfq . Result: Eighteen studies, primarily observational cohort designs, investigated outcomes among a total of 542,599 sepsis survivors. Less than half (39%) of the studies provide nationwide data. Six key themes emerged: long-term mortality risk, hospital readmissions, reduced HRQoL, long-term physical impairments, cognitive dysfunction, and mental health challenges. The most frequently reported outcomes were elevated post-hospital mortality and reduced HRQoL. Notably, 1-year mortality rates ranged from 12.5% to 36.9%. HRQoL was consistently impaired across all domains when compared to the general population. Despite ongoing needs in survivors, post-discharge rehabilitation and support services were reported to be inadequate Conclusion and recommendations: This scoping review shows that sepsis survivors in Australia experience multidimensional long-term complications and increased mortality risk. Stakeholders need to provide greater emphasis on the development of tailored post-sepsis care models and follow-up strategies to improve life after experiencing sepsis. Moreover, methodological limitations in the existing literature—including inconsistent case definitions, limited outcome measurement, short follow-up, and insufficient exploration of factors—highlight the need for robust, longitudinal research to strengthen evidence bases.
Background:Thyroid hormone alterations are common in critical illness and may reflect disease severity. Their prognostic significance in infarct-related cardiogenic shock remains incompletely defined. Methods:In this prospective cohort study from a cardiogenic shock registry, 41 patients with acute myocardial infarction complicated by cardiogenic shock underwent serial measurements of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), and free thyroxine (fT4) at baseline and 24, 48, 72, and 96 h after percutaneous coronary intervention. Associations between hormone trajectories and in-hospital mortality were assessed using longitudinal and small-sample-robust methods. Results:Thyroid trajectories diverged by outcome. Survivors maintained higher TSH concentrations over time, whereas non-survivors showed progressive suppression. fT3 declined in both groups early after presentation, with a steeper overall decline in non-survivors and outcome separation becoming most apparent later in the observation period. Lower fT3 was associated with greater illness severity and higher mortality risk. fT4 decreased over time in both groups without consistent between-group differences. Conclusions:In conclusion, dynamic alterations in thyroid hormone levels, particularly reductions in fT3, were associated with greater illness severity and adverse outcomes in cardiogenic shock. Serial thyroid function assessment may improve risk stratification in acute cardiovascular critical illness and warrants further evaluation in larger prospective studies.
Background: Long-term psychological complications of ECMO have been reported and current national guidelines state that there should be access to psychologists for patients in intensive care; however, this is not available in all ICUs. This project was based in a cardiothoracic critical care unit (CTCCU) of a hospital in the north-west of England that does not currently have a psychologist. Therefore, the aim of this project was to identify the psychological needs of ECMO patients. A subsidiary aim was to develop and trial an ECMO-specific group intervention.Methods: The prevalence of mental health difficulties in ECMO patients was investigated using data from outcome measures completed 6 weeks post-discharge. Patients were interviewed about their experiences of ECMO, and themes were identified using a thematic analysis. Based on these themes, a pilot 6-week group was developed, and quantitative and qualitative outcomes were collected.Results: Analysis of post-discharge HADS found 50% of patients scored within the clinically significant range for anxiety and 37% for depression. Patient themes included feeling powerless, alone and fears around 'what is normal?'. The ECMO group was well-received by patients, with feedback that they felt 'seen and heard'. Despite the small sample size, the group demonstrated positive outcome data, with a 66% decrease in anxiety symptoms and a 78% decrease in depression symptoms.Conclusions: This project highlighted significant mental health distress for ECMO patients. Positive psychological outcomes were gained from the ECMO group and recommendations were made that embedding psychologists within CTCCU could promote post-traumatic growth for patients.
Background: Individuals receiving invasive mechanical ventilation experience mobility limitations and are at risk for intensive care unit-acquired weakness and functional decline. Hydrotherapy has been proposed as a potential adjunct within complex care and rehabilitation pathways, as the physical properties of water may facilitate supported movement and upright activity. However, its use in ventilator-dependent populations is often avoided due to safety and feasibility concerns. This systematic review aimed to synthesize the available evidence on the safety, feasibility, and clinical implementation of hydrotherapy in this population.Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines and prospectively registered in PROSPERO. Six electronic databases were searched. Eligible studies included individuals receiving invasive mechanical ventilation who participated in clinically supervised hydrotherapy. Given heterogeneity in study designs and outcomes, a structured narrative synthesis was undertaken with emphasis on safety, feasibility, and ventilator management.Results: Six studies were included. Across all studies, hydrotherapy was consistently reported as safe, with no airway- or ventilation-related adverse events, including accidental extubation, tracheostomy displacement, ventilator disconnection, or water ingress. Feasibility was demonstrated in intensive care, rehabilitation, long-term ventilation, and pediatric prolonged mechanical ventilation settings when structured protocols, multidisciplinary staffing, and continuous physiological monitoring were employed. Reported outcomes included stable respiratory parameters, facilitated movement, and positive experiential responses.Conclusions: Although the evidence base is limited and predominantly descriptive, available findings suggest that hydrotherapy can be safely and feasibly delivered to selected individuals receiving invasive mechanical ventilation in well-resourced clinical environments.
In health, humans spend approximately one-third of their lives asleep. Sleep involves all organ systems, and it is an inherent mechanism for regulation and optimisation of bodily functions. Critical illness commonly results in a wide range of adverse health outcomes, many of which may theoretically be ameliorated by functions that are enhanced by sleep. Sleep deprivation and its subsequent organ dysfunction leads to muscle weakness, immunocompromise and the cardiovascular changes of the stress responses; these features are common features of critical illness and its sequalae. Sleep is reframed as an inherent mechanism for recovery and repair and a key mechanism for improving critical care outcomes. An understanding of how sleep affects our patients could lead to novel therapies that would enhance their recovery. This review covers sleep physiology, measurements to assess it in the critically ill, common pathological features that impact sleep during critical illness and the logical interventions and areas for research that might optimise sleep related outcomes.
This study aims to describe the gradient and the frequency with which the end tidal carbon dioxide (EtCO2) misclassifies the arterial carbon dioxide (PaCO2) in the prehospital environment. This retrospective observational study included 53 adult patients (aged ⩾ 18 years) who underwent prehospital arterial catheterisation following a traumatic mechanism who were conveyed to the regional Major Trauma Centre (MTC), 01.02.2015-17.04.2023. The PaCO2-EtCO2 gradient was more than >1 kPa difference in most patients (43/53 (81.1%)) and the ETCO2 misclassified the PaCO2 in over two-thirds of patients (38/53 (71.7%)). Overall, EtCO2 is not a reliable surrogate for PaCO2 during trauma.
Rationale:Measuring gastric residual volume (GRV) remains common in intensive care units (ICUs), despite weak evidence linking it to enteral feeding intolerance (EFI), gastric emptying, aspiration, or ventilator-associated pneumonia. Thresholds defining high GRV vary widely (75-1200 ml). This scoping review aimed to: (1) identify GRV thresholds indicating feeding intolerance in adult ICU patients; and (2) describe GRV-related management practices. Methods:This review was conducted following the Population-Concept-Context (PCC) framework. A comprehensive search was performed in PubMed and Web of Science, extracting studies published in English and Vietnamese from 2010 to 2024. Studies were eligible if they were original research, trials, pre-and-post intervention study, and case reports/case series, and reported both GRV threshold and specific management strategies, while reviews or other studies that only had either GRV cutoff or its interventions were excluded. Results:Among 73 records for screening, 25 studies were eligible. Most involved hemodynamically stable, mechanically ventilated ICU patients receiving enteral nutrition (EN). GRV monitoring was typically performed every 4-6 h, with the cutoff ranging from 150 to 500 mL. Most studies used 200-250 mL as the most frequently used reference point. Some other studies combined GRV and clinical symptoms-such as nausea, vomiting, or distension-to determine intolerance. When GRV was below the lower threshold, feeding was typically continued or increased by 10-30 mL/h. Elevated GRV prompted various interventions, including temporary suspension of EN, prokinetic administration, or transition to post-pyloric nutrition. Conclusion:Most studies used 200-250 mL as a cautious GRV threshold for an early recognition of feeding intolerance, and the time to check GRV was normally every 4-6 h. Management of high GRV for lower thresholds tended to be less absolute, by reducing feeding rate and prescribing prokinetics, while stricter management was performed if GRV exceeded the higher GRV threshold.
