Meningitis and encephalitis affect all ages, are prone to misdiagnosis and outcome can be devastating. We provide this common primer for all in the sepsis "chain-of-survival." Meningitis equals inflammation/infection of the protective membranes that cover the brain; whereas encephalitis affects the brain parenchyma. Meningitis is more common, but they can co-exist as meningoencephalitis. Encephalitis can also affect the spinal cord (encephalomyelitis). Worldwide, meningitis affects 2.5 million people annually, and kills over 200,000. Central nervous system (CNS) infections account for 3.9% of all UK intensive care unit (ICU) infections, and 0.7% of adult ICU admissions. While this means these are not common causes for admission, they do have high morbidity and mortality. The median ICU stay is 4 days, of which 3 days was the median spent requiring advanced respiratory support or support for more than one organ. The median in-hospital stay is 20 days. Most admissions come through the emergency department (ED). Signs and symptoms can be vague and varied; hence potential misdiagnosis as flu, psychiatric disorders, intoxication, even hangover. The median time between hospital admission and transfer to ICU is 1 day, and by this time approximately one-third are comatose and one-sixth need respiratory support. The risk of misdiagnosis matters given high mortality and morbidity: 18%-25% die in hospital and 1-in-10 survivors lose independence. During the past 20 years mortality has fallen, but those left with some form of permanent disability remains constant at nearly 40%. Fortunately, early recognition and treatment can greatly improve outcome. Regarding diagnosis, history and physical examination still have great value. Next, lumbar puncture (LP) should be expedited unless contraindicated by coagulopathy, skin infection, or raised ICP. LP testing should incorporate opening pressure, microscopy, culture and cell count, glucose and protein and often polymerase chain reaction (PCR) for meningococcus, pneumococcus, herpes simplex virus (HSV1&2), varicella (VZV) and enterovirus. Radiologically, head computed tomography (CT) is first line. It may reduce the risk of LP by excluding pathologies likely to trigger herniation. CT is indicated if their Glasgow Coma Score (GCS) is falling or ⩽9, or if seizures, focal neurological signs or papilloedema. Normal CT cannot rule out raised ICP, but LP is avoided if the CT shows herniation, basal cistern or foramen magnum effacement, cerebral swelling, intracranial lesions/collections with mass effect or obstructive hydrocephalus. Magnetic resonance imaging (MRI) is logistically tougher but better at detecting meningitis/encephalitis. MRI can suggest the causative organisms, along with complications such as infarct, pus and parenchymal changes. Treatment centres on prompt antimicrobials: usually a third-generation intravenous (IV) cephalosporin, typically within 1 h, and at an increased (i.e. "meningitis") dose. Intravenous amoxicillin is added in the elderly or immunocompromised, plus aciclovir if viral encephalitis is plausible. Treatment delays (over 4 h) are associated with increased mortality. Over half (57%) of patients that require ICU develop intracranial complications, most frequently ischaemia, cerebral oedema and ventriculitis. In short, these diseases are life-threatening but manageable if we do the simple stuff right. . .and right away.

•HSV-1 reactivation is associated with clinical deterioration in critically ill COVID-19 patients.•Bronchoscopic findings associated with HSV-1 reactivation were ulcers, plaque-like lesions, haemorrhage and desquamation.•Prognosis was found to be poor in critically ill COVD-19 patients with HSV reactivation.

Abstract Introduction In 2022 Nottingham University Hospital NHS Trust (NUH) began offering structured prehabilitation sessions for patients diagnosed with cancer, to help them better prepare for surgical treatment. We have undertaken an audit of patients enrolled onto the programme and examined key outcomes. Methods Patients requiring surgery for cancer were initially assessed (April – Oct 2022) and offered 2-3 prehabilitation sessions per week. During initial and final Prehabilitation assessments, patients completed a sit-stand test, shuttle walk test and Patient Reported Outcome Measures for anxiety (GAD-7) and depression (PHQ-9). Results Two hundred and twelve patients were enrolled onto the prehabilitation programme and 87 (41%) completed the pre- and post-assessment after 3-6 weeks. Colorectal (47, 54%) and gynaecological (17, 22%) surgery represented the two major procedures for those completing the programme. Mean (±sem) physical activity score (140.1±19.4, n=78) was significantly increased (p<0.001) at the end of the programme (315.3±23.8). Mean shuttle walk test score (340.2±28.7, n=54) increased by approximately 15% (p<0.001) at the end of the programme (394±32.8), while the sit-stand test (24.9±1.3, n=64) also improved significantly (30.9±1.5; p<0.001). The mean (±sem) anxiety GAD-7 score (6.06±0.64 n=85) and depression PHQ-9 score (5.38±0.69, n=85) were significantly reduced (p<0.001) by the programme (3.29±0.46 and 2.76±0.45, respectively). Conclusion Initial results from the NUH prehabilitation programme provide evidence for a significant increase in physical activity prior to surgery, accompanied by a general improvement in the mental well-being of the patients.

BACKGROUND:Evidence suggests that physical fitness interventions, mental health support and nutritional advice before surgery (prehabilitation) could reduce hospital stay and improve quality of life of patients with cancer. In this study we captured the opinions of a group of patients with cancer undergoing these interventions after treatment to discover what a prehabilitation programme should encompass.METHODS:Patients from the Cancer and Rehabilitation Exercise (CARE) programme based in Nottingham took part in a 26-point online questionnaire about the design of prehabilitation programmes.RESULTS:The questionnaire was completed over a 2-week period in December 2021 by 54 patients from the CARE programme. Their responses were as follows: 44 (81.5%) participants would have participated in prehabilitation had it been available to them and 28 (51.9%) ranked physical exercise as the most important component. Forty (74.1%) participants believed the counselling aspect of prehabilitation would have contributed to a successful outcome and 35 (64.8%) thought dietary advice would have benefitted them before surgery. Thirty-one (57.4%) participants preferred the programme to take place in a fitness centre, rather than at home or hospital and 43 (79.6%) would have liked to have known about prehabilitation from their doctor at the time of diagnosis.CONCLUSIONS:Patients are interested in prehabilitation to become more physically fit and mentally prepared for surgery. They expressed the need for a focus on physical exercise, counselling to improve mental health and personalised nutritional advice. Tailoring a prehabilitation programme, with input from patients, could contribute to improving patient outcomes following cancer treatments.

Abstract Introduction Oesophagectomy for oesophageal cancer is associated with post-operative complications and physiological instability, with cardio-respiratory disturbance in up to 30% of patients. Oesophagectomy patients are regularly admitted to an intensive care unit (ICU) for the first 24 hours after surgery. Increased demand for ICU beds has sparked interest in identifying patients who could be managed in lower intensity environments. We examined pre-operative features potentially associated with increased complication risk. Methods Data from 526 patients who underwent elective oesophagectomy 07/01/2015 - 10/12/2019 was reviewed with basic demographic data available for 485. From 211 patients, data relating to past medical history, American Society of Anesthesiology score (ASA), prescription drug history, and pre-operative blood tests was retrospectively analysed [SPSS v.28; IBM, Chicago] to identify features associated with prolonged ICU stay. Results Median length of post-operative ICU stay was 31 hours. 327 (67.4%) remained on ICU <48 hours, and 158 (32.6%) ≥48 hours. Age >70, ASA ≥3, and female sex were associated with stay ≥48 hours (p=0.044; p=0.036; p<0.001). Increased pre-operative white cell count and serum urea were associated with prolonged ICU stay (p=0.002; p=0.007), as was lower sodium and albumin (p=0.002; p=0.02). Conclusion Predicting which patients are more likely to require prolonged ICU support after oesophagectomy may allow others to be admitted to lower dependency beds. The associations identified could be used in future multivariate analysis to derive a pre-operative scoring system.

Abstract Introduction Three prehabilitation programmes for patients undergoing surgery for cancer, based around initial physical activity scores, commenced April 2022. An audit of key outcomes was undertaken on patients enrolled onto the main programmes. Methods Patients with cancer requiring surgery were initially assessed (April to Oct 2022) and offered 2-3 sessions per week at one of: a community-based gym with registered trainers, a hospital-based gym, or a programme to train at home. Here we report physical activity scores and incremental shuttle walk test at the beginning and end of the programme, in addition to the hospital length of stay (LoS). Results The mean (±sem) physical activity score for hospital gym patients (54.4±18.3, n=23) was significantly lower (p<0.001) than for those attending the community gym (180.5±26.5 n=47), but both groups showed a significant improvement (p<0.001) at the end of the programme (216.7±18.3 and 362.0±31.0, respectively). The initial mean (±sem) incremental shuttle walk test score for the hospital gym patients (126.5±19.8, n=17) was significantly lower than for those attending community gyms (415.6±30.1, n=34), but only those at the latter (487.1±29.1) managed a significant increase (p<0.001). Thirty-seven patients requiring colon surgery completed the prehabilitation programme. The median (IQR) LoS [5.2 (3.4-7.3) days] was significantly lower for these patients (p<0.05) compared with those at NUH who did not enter the programme [5.6 days (4.3-8.2) n=567]. Conclusion The prehabilitation programme increased physical activity for both normal and frail patients with cancer prior to surgery and this was associated with a reduction in LoS.

Background Critical incident reporting can be applied to cardiopulmonary resuscitation (CPR) events as a means of reducing further occurrences. We hypothesized that local CPR-related events might follow patterns only seen after a long period of analysis. Design We reviewed 6 years of local incidents associated with cardiac arrest calls. The following search terms were used to identify actual or potential resuscitation events: “resuscitation,” “cardio-pulmonary,” “CPR,” “arrest,” “heart attack,” “DNR,” “DNAR,” “DNACPR,” “Crash,” “2222.” All identified incidents were independently reviewed and categorized, looking for identifiable patterns. Setting Nottingham University Hospitals is a large UK tertiary referral teaching hospital. Results A total of 1017 reports were identified, relating to 1069 categorizable incidents. During the same time, there were approximately 1350 cardiac arrest calls, although it should be noted that many arrest-related incidents were not associated with cardiac arrest call (e.g., failure to have the correct equipment available in the event of a cardiac arrest). Incidents could be broadly classified into 10 thematic areas: no identifiable incident (n = 189; 18%), failure to rescue (n = 133; 12%), staffing concerns (n = 134; 13%), equipment/drug concerns (n = 133; 12%), communication issues (n = 122; 10%), do-not-attempt-CPR decisions (n = 101; 9%), appropriateness of patient location or transfer (n = 96; 9%), concerns that the arrest may have been iatrogenic (n = 76; 7%), patient or staff injury (n = 43; 4%), and miscellaneous (n = 52; 5%). Specific patterns of events were seen within each category. Conclusions By reviewing incidents, we were able to identify patterns only noticeable over a long time frame, which may be amenable to intervention. Our findings may be generalizable to other centers or encourage others to undertake this exercise themselves.

Introduction. During previous viral pandemics, reported co-infection rates and implicated pathogens have varied. In the 1918 influenza pandemic, a large proportion of severe illness and death was complicated by bacterial co-infection, predominantly Streptococcus pneumoniae and Staphylococcus aureus . Gap statement. A better understanding of the incidence of co-infection in patients with COVID-19 infection and the pathogens involved is necessary for effective antimicrobial stewardship. Aim. To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England. Methodology. A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 h following hospital admission, corresponding to community and hospital-acquired co-infections. Results. Of 254 patients studied (median age 59 years (IQR 49–69); 64.6 % male), 139 clinically significant organisms were identified from 83 (32.7 %) patients. Bacterial co-infections/ co-colonisation were identified within 48 h of admission in 14 (5.5 %) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli . The co-infection/ co-colonisation rate >48 h after admission was 27/1000 person-days (95 % CI 21.3–34.1). Patients with co-infections/ co-colonisation were more likely to die in ICU (crude OR 1.78,95 % CI 1.03–3.08, P=0.04) compared to those without co-infections/ co-colonisation. Conclusion. We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay.

Objective To describe the incidence and nature of co-infection in critically ill adults with COVID-19 infection in England. Methods A retrospective cohort study of adults with COVID-19 admitted to seven intensive care units (ICUs) in England up to 18 May 2020, was performed. Patients with completed ICU stays were included. The proportion and type of organisms were determined at <48 and >48 hours following hospital admission, corresponding to community and hospital-acquired co-infections. Results Of 254 patients studied (median age 59 years (IQR 49-69); 64.6% male), 139 clinically significant organisms were identified from 83(32.7%) patients. Bacterial co-infections were identified within 48 hours of admission in 14(5.5%) patients; the commonest pathogens were Staphylococcus aureus (four patients) and Streptococcus pneumoniae (two patients). The proportion of pathogens detected increased with duration of ICU stay, consisting largely of Gram-negative bacteria, particularly Klebsiella pneumoniae and Escherichia coli . The co-infection rate >48 hours after admission was 27/1000 person-days (95% CI 21.3-34.1). Patients with co-infections were more likely to die in ICU (crude OR 1.78,95% CI 1.03-3.08, p=0.04) compared to those without co-infections. Conclusion We found limited evidence for community-acquired bacterial co-infection in hospitalised adults with COVID-19, but a high rate of Gram-negative infection acquired during ICU stay.

If you ask health professionals about their experiences of resuscitation, they will sometimes tell you about a case that somehow bit deeper into them than they expected. It goes without saying that some events in medicine are more poignant, more disturbing, or more stressful than others. Sometimes, however, upsetting events can have effects that stray past the boundaries of work and into our personal lives. This begs the question: can we can spot those cases likely to affect us in this way? Or perhaps instead we could identify individuals most likely to be affected? In either case, can we do anything about it or is this just part and parcel of being a doctor or nurse? The presence of psychological trauma symptoms in resuscitation providers and an exploration of debriefing practicesResuscitationVol. 142PreviewWitnessing traumatic experiences can cause post-traumatic stress disorder (PTSD). The true impact on healthcare staff of attending in-hospital cardiac arrests (IHCAs) has not been studied. This cross-sectional study examined cardiac arrest debriefing practices and the burden of attending IHCAs on nursing and medical staff. Full-Text PDF

Airway management outside the operating room is associated with increased risks compared with airway management inside the operating room. Moreover, airway management—whether in the intensive care unit, emergency department, interventional radiology suite, or general wards—often requires mastery of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. The 2015 Difficult Airway Society Guidelines encourage the airway team to “stop and think”. This article provides a practical review of how that evidence applies during emergency airway management outside of the operating room. To counter the challenges of airway management outside the operating room, we offer a mnemonic that combines both technical and non-technical insights summarized using the seven letters of the word PREPARE (P: pre-oxygenate/position; R: reset/resist; E: examine/explicit; P: plan A/B; A: adjust/attention; R: remain/review; E: exit/explore). We hope it can unite potentially disparate personnel with a structure that allows them to make acute decisions, coordinate action, and communicate unequivocally. This multidisciplinary publication also hopes to encourage common understanding and language between anesthesiologists and non-anesthesiologists about the perils of airway management outside the operating room and the importance of airway teamwork.

It has been said that intensivists are the general practitioners of the hospital. Not only do they have to have an in depth understanding of their own field, they also need to have insight into the workings of almost every other hospital discipline. The breadth of knowledge needed to pass an exam in intensive care medicine could seem extremely daunting, like revising to be a jack of all trades – and master of one. It must also be said that there is an art to passing exams. Knowledge needs to be: structured, up-to-date, and comprehensive yet succinct. Judged by those criteria, Revision Notes in Intensive Care Medicine does rather a good job. It manages to concisely cover all the relevant topics, despite being A5 size and only 480 pages. In fact, the small size is an advantage, as it is small enough to carry around and dip into. As part of the Oxford Specialty Training range, it follows a well-trodden path in being divided into chapters that cover Respiratory, Cardiovascular, Renal, etc. The book also goes further by including chapters on Ethics, Law & Communication, Death and Dying, and Organizational Issues. Each chapter is then further subdivided, covering major aspects of physiology or disease-management. The layout is well structured and logical, making it very clear and easy to follow. I think it's fair to say that if you are not a fan of bullet-points, then this is not the book for you. That said, the format of the book suits its stated aim: it is a revision aid, and it is unashamedly reductionist, using short pithy statements, facts, or tables wherever possible. If I had to find fault, it would be worth mentioning that there aren't many figures or diagrams, meaning that the text is sometimes rather dense. However, if passing an exam is all about learning how to “classify or die”, then this book is right on the money. It's also true that there isn't much that is ground-breaking or novel – but again, that's not the point. It is clearly well-researched, and takes account of contemporary literature. It isn't afraid of indicating where current theories are conflicting or contentious. It includes useful suggestions for further reading, highlighting key references or review articles at the end of each relevant section within a chapter. It even has a short section at the end listing what it considers to be key papers in the field of intensive care medicine. Of course, it's always going to be possible for an intensivist to find fault or to identify omissions. For example, the section on perioperative care refers to a select handful of surgical procedures. Likewise, some clinicians, particularly those who are super-specialized, may disagree with various conclusions or suggested management techniques. Any such criticisms, however, are likely to be minor, and should not detract from how well this book distils the key points relevant to modern intensive care management into workable format that is easy to read and easy to learn from. The book is aimed, fairly and squarely, at intensive care trainees, although that's not to say that it won't be useful to other groups who might, from time to time, need access to a short summary of a topic. My copy is going to live on the office shelf, ready for me to delve into the next time a trainee comes and asks for viva practice. After all, we all need to revise from time to time. Overall, I would say this book fares very well in achieving its aims. It is comprehensive in its scope, and rapidly drills down into the essentials.

The Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults 1 provocatively include deliberate instructions to ''stop and think'' (Figure).In so doing, they remind us that management of the difficult and failed airway is as much cerebral and situational as it is procedural and anatomical. 2 The new guidelines are established on a growing evidence base.Accordingly, from a technical point of view, the authors recommend limiting intubation attempts, performing earlier scalpel cricothyrotomy, and avoiding blind techniques. 1 More pertinent to this review, the authors also promote the evidence base supporting the importance of psychological factors, structured communication, and regular practice.3][4][5] These guidelines advance the field in many ways, not the least of which is the implicit message that successful difficult airway management requires the use of our hands, brains, and voices.It is important not to oversimplify the technical aspects of airway management.Similarly, the discussion of nontechnical factors, including analogies to other highreliability industries such as aviation, should not be oversimplified. 6After all, planes often do not take off during particularly inclement weather, whereas practitioners confronted by patients with a difficult or failed airway frequently have to ''fly into the storm''.5][6] Despite being leaders in medicine, the subspecialties of anesthesia and critical care are still in their infancy compared with other high-stakes systems.4][5] The instruction to ''stop and think'' applies on many levels. Airway management: updating our approachThe ''difficult airway'' is typically defined as ''that clinical situation in which a conventionally trained anesthesiologist experiences difficulty with bag-mask ventilation, difficulty with insertion of an extraglottic device, or difficulty with tracheal intubation''. 7The ''failed airway'' is typically defined as ''failure to intubate within three attempts, failure at bag-mask ventilation, failure to insert an extraglottic device, or failure to maintain oxygen saturation above 90%'' -the so-called ''can't intubate, can't oxygenate''. 2

BACKGROUND:Statins may have immunomodulatory effects that benefit critically ill patients. Therefore, we retrospectively examined the association between survival and the prescription of statins prior to admission to an intensive care unit (ICU), or high dependency unit (HDU), as a result of major elective surgery or as an emergency with a presumed diagnosis of sepsis.METHODS:We retrospectively studied critical care patients (ICU or HDU) from a tertiary referral UK teaching hospital. Nottingham University Hospitals have more than 2200 beds, of which 39 are critical care beds. Over a 5-year period (2000-2005), 414 patients were identified with a presumed diagnosis of sepsis, and 672 patients were identified who had planned ICU/HDU admissions following elective major surgery. Patients prescribed statins prior to hospital admission were compared with those who were not. Demographics, medical history, drug history, and Acute Physiology and Chronic Health Evaluation II scores were examined. Univariate and multivariate analyses were applied using the primary end point of survival at 5 years after admission.RESULTS:Patients prescribed statins prior to critical care admission were, on average, older and had higher initial Acute Physiology and Chronic Health Evaluation II scores and more preexisting comorbidities. Statins were almost invariably stopped following admission to critical care. Statin use was not associated with significantly altered survival during hospital admission, or at 5 years, for either patients with sepsis (9% vs 15%, P=.121; 73% vs 84%, P=.503, respectively) or postoperative patients (55% vs 58%, P=.762; 57% vs 63%, P=.390).CONCLUSIONS:Prior statin use was not associated with improved outcomes in patients admitted to critical care after elective surgical cases or with a presumed diagnosis of sepsis.

short chapters intended to cover fundamental surgical knowledge for non-surgeons.The authors focus