Introduction: Prolonged time to asystole is a common barrier to successful organ donation after circulatory death, yet there have been few attempts to evaluate trends in its occurrence over time. This study investigated temporal trends in time to asystole among patients considered for donation after circulatory death in the UK (2014-2024). Methods: This observational study was conducted using NHS Organ Donation & Transplant (ODT) datasets. We analysed temporal trends in time to asystole and donation outcomes using descriptive statistics. Additionally, to explore evident impacts of the COVID-19 pandemic we performed pre-post comparisons and an interrupted time series (ITS) analysis. Results: Of 9466 participants, 58.5% proceeded to solid organ donation. Non-proceeding cases were primarily due to prolonged time to asystole (55.1%). Donation rates increased from 50% to 60% pre-2020 to consistently above 60% post-2022, whilst cases not proceeding due to prolonged time to asystole decreased from 25% to 20%. ITS analysis confirmed a significant post-pandemic reduction in time to asystole and a sustained drop in referrals, suggesting improved donation efficiency. Successful donors typically received higher levels of support and had lower neurological status compared to those with prolonged time to asystole. Discussion: The findings demonstrate reduced prolonged time to asystole occurrence and increased organ donation rates. Whilst there has been ongoing improvement over the study period there is evidence of a systemic change following the COVID-19 pandemic, which resulted in a smaller, more efficient referral pool. This may be attributed to better identification of suitable donors during the referral process, and while causation cannot be definitively established, the study supports ongoing evaluation and refinement of the donation pathways.

INTRODUCTION:Advancing research in severe burn injury is challenging as the decreasing incidence in developed countries leads to underpowered studies. Although there is a significant need for research, any new studies ought to be considered of high priority to the clinical community to ensure efficiency of effort. We aimed to establish the foremost clinician-derived research priorities in UK burns critical care. METHODS:A modified Delphi approach was adopted to identify topics of research priority to the burns critical care community. Clinician representatives from burns units across the UK were invited to suggest unanswered research questions. These were refined into a list of indicative questions. A literature review excluded those that were already addressed. Unanswered indicative questions proceeded through two Delphi rounds, with a 24-member expert panel. Questions meeting the predetermined consensus thresholds underwent prioritisation and final ratification. RESULTS:The initial survey generated 79 indicative questions. After two Delphi rounds, 50 questions were shortlisted. The prioritisation exercise reduced these to 14 high priority research questions. At final ratification, further refinement produced the 11 highest priority areas for research. These spanned key themes including resuscitation, inhalation injury, infection, pharmacotherapy and prognostication. DISCUSSION:This study established the 11 highest priority research areas in burns critical care, as determined by UK clinical experts working in this field. These priorities provide a roadmap for future burns critical care research, helping to direct funding and resources toward areas with the greatest potential to enhance patient outcomes and advance clinical practice.

BACKGROUND:Acute hypoxaemic respiratory failure (ARF) is the leading cause of intensive care unit (ICU) admission among immunocompromised patients. However, contemporary data regarding the epidemiology, management, and outcomes of ARF in this population remain scarce. We aimed to identify predictors of mortality and intubation in immunocompromised patients admitted to the ICU with ARF. METHODS:This retrospective observational study was conducted in 103 ICUs in 26 countries. Adults (≥18 years) with ARF and immunodeficiency were eligible for inclusion. Patient data, including information on the nature of underlying immunosuppression, the cause of ARF, and the oxygenation strategy, were obtained from electronic medical records or medical charts. The primary outcome was to report 30-day mortality and identify associated factors in patients with complete data for all variables. Cox proportional hazards models were used to identify variables associated with mortality, and differences between groups were compared with χ2 tests or two-sided Wilcoxon rank-sum tests, with p values of less than 0·05 considered significant. FINDINGS:9854 immunocompromised patients with ARF admitted to participating ICUs between Jan 1, 2017, and Dec 31, 2023, were included in the study. The median age was 64 years (IQR 54-71); 3941 (40·0%) patients were female and 5913 (60·0%) were male. The main causes of immunodeficiency were a haematological malignancy (4759 [48·3%] of 9854 patients) or solid malignancy (3818 [38·7%] patients). Infection was the leading cause of ARF (6610 [62·0%] of 9854 patients); 5288 (53·7%) patients had more than one contributing cause of ARF, and no cause was identified in 1490 (15·1%) patients. The median partial pressure of oxygen in arterial blood (PaO2)/fractional concentration of oxygen in inspired air (FiO2) ratio was 198 [IQR 141-208]. The 30-day mortality rate was 47·3% (4662 patients). Predictors of higher mortality were older age (hazard ratio 1·01 [IQR 1·00-1·02]), higher Charlson Comorbidity Index score (1·04 [1·01-1·07]), higher Frailty Index score (1·22 [1·16-1·28]), longer time from hospital to ICU admission (1·02 [1·01-1·03]), higher respiratory rate (1·02 [1·02-1·03]), coma at ICU admission (2·04 [1·72-2·43]), invasive fungal infection as cause of ARF (1·82 [1·45-2·28]), disease-specific infiltrates (1·73 [1·32-2·26]), unidentified cause of ARF (2·16 [1·74-2·68]), and use of vasoactive drugs (2·45 [2·10-2·86]) or renal replacement therapy (2·07 [1·74-2·48]). Protective factors included receipt of a solid organ transplant (0·62 [0·49-0·79]), systemic vasculitis or connective tissue disease (0·61 (0·47-0·78]), higher PaO2/FiO2 ratio (0·78 [0·72-0·84]), receipt of high-flow nasal oxygen therapy (0·78 [0·64-0·95]), and cardiogenic pulmonary oedema (0·67 [0·51-0·89]). INTERPRETATION:In this large international cohort of immunocompromised patients with ARF, we identified key risk and protective factors for mortality and intubation. These findings could improve outcomes by informing timely clinical decisions, goals-of-care discussions, and management in this vulnerable population. FUNDING:Kirsten and Freddy Johansen Foundation and Groupe de Recherche en Réanimation Onco-Hématologique.

INTRODUCTION:Hyperpyrexia is a complication of burn injury, likely caused by systemic inflammation and infection, the pathophysiology of which is poorly understood. This study aimed to describe the patient cohort who developed hyperpyrexia (≥39.5°C) and evaluate the effectiveness of the Thermogard XP Icy®, an intravascular temperature management device, in restoring normothermia. METHODS:This was a retrospective cohort study of adult patients admitted to Glasgow Royal Infirmary's intensive care unit with major burns (TBSA ≥20%) between January 2016 and October 2024. A central database and electronic medical records were used to collect data on demographics, burn severity, interventions and outcomes. Episodes of hyperpyrexia and Thermogard XP® use were also recorded. A multilevel interrupted time series analysis was used to assess the effectiveness of the Thermogard XP® device in reducing body temperature in comparison to historic controls. RESULTS:Fifty-six patients were analysed, of which 30 (56.3%) developed hyperpyrexia. This cohort were more likely to have sustained a flame burn (p = 0.003), have a greater burn TBSA (p = 0.006) and longer hospital stay (p = 0.005) when compared to non-hyperpyrexic patients; however, mortality rates did not differ significantly. Eight patients were managed with a Thermogard XP®; this appeared to achieve normothermia quicker than standard interventions. CONCLUSION:Hyperpyrexia was associated with more severe burn injuries and greater intervention requirements but not increased mortality. The Thermogard XP® seemed effective at controlling temperatures ≥ 39.5°C in this small single-centre observational study; future studies are needed to further explore its effectiveness and impact on outcomes such as survival.

Medication interventions are fundamental to the care of the critically ill patient in the intensive care unit (ICU), relying on effective and appropriate delivery of the medication use process. Medication errors affect a high proportion of patients in the ICU. This scoping review maps the literature pertaining to medication errors and preventable adverse drug events in the adult ICU. We searched seven electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane, Google Scholar), identifying 2960 records. After screening against predefined eligibility criteria, 48 records were included for data extraction. A high variation in incidence of medication errors and preventable adverse drug events were reported, reflecting the heterogeneity in study designs, surveillance methods and preventability assessments. Associated risks factors include patient (high severity of illness, older age), clinical (renal dysfunction, prolonged ICU stay), staff (staff inexperience, role overload), environmental (interruptions, transfer of care) in addition to high-risk medications. The rate of serious or life-threatening harm was low at 1–5

BACKGROUND:Platelet transfusions are frequent in the Intensive Care Unit (ICU), either as prophylaxis against bleeding complications or as treatment for bleeding. The European Society of Intensive Care Medicine guidelines for ICU patients generally recommend not using prophylactic platelet transfusions unless the platelet count falls below 10 × 109 cells/L in non-bleeding patients and make no recommendation for platelet transfusion threshold in non-massively bleeding patients with thrombocytopenia. Therefore, the decision to transfuse platelets is often left to clinical assessment by the treating physician. This study aims to describe current platelet transfusion preferences among ICU physicians. METHODS:An online, anonymous survey consisting of 43 items was produced in two languages (French and English) and distributed by investigators in the Nine-I research network to ICU physicians in Europe and the United States of America. The survey evaluated platelet transfusion practices in ICU patients with and without bleeding, the presence of local guidelines, and factors influencing the decisions to transfuse platelets. Only completed surveys were analysed. RESULTS:We received 997 surveys completed by ICU physicians. Overall, there was large heterogeneity in platelet transfusion practices between and within countries. In non-bleeding, thrombocytopenic medical ICU patients, most would transfuse prophylactic platelets at a platelet count threshold of 10 × 109 cells/L. Thirty percent would change their strategy in patients with bone marrow failure and either be more liberal (60%; 95% Confidence Limits 0.54, 0.66), more restrictive (31%; 0.26,0.36) or seek assistance. Higher thresholds were preferred in surgical patients, prior to procedures and in patients with bleeding. Only 173 (17%; 0.15,0.19) responded that they were confident about the clinical indications every time they prescribed a platelet transfusion. As for existing guidelines, only 123 (12%; 0.10,0.15) responded that they always read them. Colleagues' attitudes and departmental culture were important influencers on transfusion practice. CONCLUSION:Platelet transfusion practice in the ICU is heterogeneous, both between and within countries; guidelines are often not used, and there is often uncertainty about the clinical indication.

Bayesian analysis is being used with increasing frequency in critical care research and brings advantages and disadvantages compared to traditional Frequentist techniques. This study overviews this methodology and explains the terminology encountered when appraising this literature. Setting different priors can impact the interpretation of new results, and we describe an approach to understanding this. Finally, the strengths and challenges of adopting a Bayesian analysis compared to Frequentist techniques are explored.

Hematological malignancies (HMs) are increasingly associated with life-threatening complications requiring intensive care unit (ICU) management. Recent advancements in therapies, diagnostics, and critical care protocols have improved outcomes for these patients, yet significant challenges persist. This manuscript explores the evolving landscape of critical care in hematology, emphasizing the unique complications, management strategies, and future directions in the field. Patients with HMs are particularly vulnerable to infections, sepsis, organ dysfunction, and treatment-related toxicities such as cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and coagulopathies. Innovations in the management of acute respiratory failure, septic shock, and invasive fungal infections have contributed to better survival rates, yet outcomes remain suboptimal for certain high-risk groups. Furthermore, new therapies, including CAR-T cells, bispecific antibodies, and immune checkpoint inhibitors, present both opportunities and challenges in the ICU setting due to their potential toxicities. Emerging trends emphasize the importance of early ICU admission, multidisciplinary collaboration, and precision medicine in improving patient care. The integration of biomarker-driven strategies, advanced diagnostics, and artificial intelligence holds promise for optimizing therapeutic interventions and enhancing antimicrobial stewardship. Additionally, patient-centered approaches, including time-limited trials and goal-oriented discussions, aim to balance aggressive care with quality-of-life considerations. This review underscores the need for continued research to address disparities in access to care, improve long-term outcomes, and develop standardized protocols for managing critically ill hematology patients. By advancing the integration of oncology and critical care, clinicians can better navigate the complexities of modern therapies and provide holistic, evidence-based care that aligns with patient values and priorities.

Fluid management is a critical component in the treatment of patients suffering with major burns. Clinicians must carefully balance judicious resuscitation with the risks of over- or under-resuscitation. We aimed to identify factors associated with survival in burns patients and determine the importance of resuscitation practices. Patients requiring admission to Burns Services in the United Kingdom between 1 April 2022 and 31 March 2023 were included in the National Burns Audit project on fluid resuscitation practices, to evaluate factors associated with survival and Critical Care Length of Stay (CCLoS). A total of 198 patients were included in the analyses, with median age of 51 years (interquartile range, (IQR) 35–62 years), median Total Burn Surface Area (TBSA%) of 27.5% (IQR 20–40%), and median Baux score 82.5 (IQR 66–105). The following were found to be significant for survival: younger age, smaller TBSA%, lower Baux score and independence from renal replacement therapy. Neither the mechanism of burns nor the fluid resuscitation volumes appeared to influence survival. Although interventions such as tracheostomy or the number of surgical procedures did not appear to affect survival, fluid replacement of more than 6 mL/kg/%TBSA independently predicted longer CCLoS. Volume of fluid resuscitation, within the limits examined in this cohort, did not impact likelihood of survival.

Immunosuppression, characterised by impaired immune function, significantly influences infection risk and ICU admissions in critically ill patients. This manuscript highlights the need for grading criteria to assess pre-existing immunosuppression, considering factors like underlying diseases, immunosuppressive therapies, and clinical outcomes variability. We propose a grading system categorising immunosuppression as mild, moderate, or severe. These criteria, while preliminary, offer a foundation for future refinement. Patients with moderate immunosuppression may require closer infection surveillance, while those with severe immunosuppression might need early immune reconstitution therapies. Prospective studies integrating biomarkers and advanced tools like machine learning are essential to validate and enhance the grading system for clinical use. This approach aims to make immunosuppression assessments more predictive and actionable. This narrative review synthesises current knowledge and provides guidance for individualised management. Effective care requires balancing immunosuppressive treatments with infection prevention, including risk assessments, optimisation, and medication reconciliation. Ultimately, the manuscript advocates for developing robust grading criteria to improve clinical decision-making and outcomes for critically ill immunocompromised patients. Funding Not receiving any funding.

BACKGROUND:Platelet transfusions are frequently used in the Intensive Care Unit (ICU) as prophylaxis against bleeding complications. Several guidelines exist on when to administer platelet transfusions in the ICU, but studies indicate that these guidelines are not necessarily followed. The aim of this qualitative study was to understand how experienced ICU physicians make decisions on prescribing prophylactic platelet transfusions and to gain insight into their general concerns and views on blood product transfusions. DESIGN:Descriptive qualitative study using semi-structured, in-depth interviews with clinicians working in ICUs in Austria, Denmark, France, Germany, Spain, and the United Kingdom. The interviews were recorded, transcribed verbatim, and analyzed using thematic analysis. RESULTS:We identified four main themes influencing the decision to prescribe prophylactic platelet transfusions: Guidelines, social and cultural aspects (including religion), previous personal experiences, and fear of consequences. DISCUSSION:Most doctors expressed uncertainty about balancing benefits and harm. Platelet transfusions were often used to prevent bleeding despite uncertainty on the effect and were typically triggered by fear of consequences when performing a procedure, which was an important driver. The departmental culture and colleagues' attitudes were far more important influencers on decision-making than guideline recommendations. Most doctors thought it was possible for blood products to transfer unknown and potentially harmful substances to patients, although this did not appear to influence their daily practice.

Background: Acute kidney injury (AKI) within the intensive care unit (ICU) is common but evidence is limited on longer-term renal outcomes. We aimed to model the trend of kidney function in ICU survivors using estimated glomerular filtration rate (eGFR), comparing those with and without AKI, and investigate potential risk factors associated with eGFR decline. Methods: This observational cohort study included all patients aged 16 or older admitted to two general adult ICUs in Scotland between 1st July 2015 and 30th June 2018 who survived to 30 days following hospital discharge. Baseline serum creatinine and subsequent values were used to identify patients with AKI and calculate eGFR following hospital discharge. Mixed effects modelling was used to control for repeated measures and to allow inclusion of several exploratory variables. Results: 3649 patients were included, with 1252 (34%) experiencing in-ICU AKI. Patients were followed up for up to 2000 days with a median 21 eGFR measurements. eGFR declined at a rate of -1.9 ml/min/1.73m2/year (p-value < 0.001) in the overall ICU survivor cohort. Patients with AKI experienced an accelerated rate of post-ICU eGFR decline of -2.0 ml/min/1.73m2/year compared to a rate of -1.83 ml/min/1.73m(2)/year in patients who did not experience AKI (p-value 0.007). Pre-existing diabetes or liver disease and in-ICU vasopressor support were associated with accelerated eGFR decline regardless of AKI experience. Conclusions: ICU survivors experienced a decline in kidney function beyond that which would be expected regardless of in-ICU AKI. Long-term follow-up is warranted in ICU survivors to monitor kidney function and reduce morbidity and mortality.

The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.

Background: Patients who have survive a burn injury might be at risk of opioid dependence after discharge. This study examined the use of opioids in patients who suffer burn injury and explored factors associated with persistent opioid use after hospital discharge. Methods: This retrospective cohort study compared adults admitted with a burn injury from 2009 to 2019 with two matched comparison cohorts from the general population and adults with a diagnosis of acute pancreatitis. Preadmission prescription opioid use was determined, and a multivariable negative binomial regression analysis used to explore post -discharge opioid use. Results: A total of 7147 burn patients were matched with 6810 pancreatitis patients and with 28 184 individuals from the general population. Pre-admission opioid use was higher in the burn and pancreatitis cohorts (29% and 40%, respectively) compared with the general population (17%). Opioid use increased in both burn and pancreatitis cohorts after discharge (41% and 53%, respectively), although patients with pancreatitis were at even higher risk of increased opioid use in an adjusted analysis (incidence rate ratio 1.43). Female sex, lower socioeconomic status, ICU admission, pre -injury opioid use, and a history of excess alcohol use were all associated with an increase in opioid prescriptions after discharge. Conclusions: Opioid use is high in those admitted with a burn injury or acute pancreatitis when compared with the general population, increasing further after hospital discharge. Female sex and socioeconomic deprivation are among factors that make increased opioid use more likely, although this phenomenon seems even more pronounced in those with acute pancreatitis compared with burn injuries.

Background: Studies suggest increased occurrence of cancer in persons who have experienced a burn injury with hospital admission. Objective: To determine the incidence of cancer among those hospitalised for burn injuries in Scotland compared with a similar group without a history of burn injury hospitalisation. Method: A retrospective cohort design was used to compare cancer (ICD10 C00-97, excluding C44) incidence in two groups: 6805 burn injury patients discharged from Scottish hospitals between 2009 and 2019, and 25,946 subjects from the general population who were matched to burn patients by sex, year of birth, and degree of social deprivation. Cancer incidence was identified from the Scottish cancer registry. Cox proportional hazard regression was used to model time to cancer incidence adjusting for age, sex, degree of deprivation and presence of a comorbidity. Cancer risk was presented as standardised incidence ratios (SIRs) and hazard ratios (HR). Results: We found a higher prevalence of pre-existing conditions, particularly alcohol abuse among patients with burns. Pre-existing cancers were more common in the burn cohort (3.5%) than the comparison group (1.7%) and were excluded from further analysis. Over a median follow-up of 4-5 years, a total of 236 (3.5%) burn patients and 969 (3.7%) persons in the comparison group were diagnosed with cancer. At 0-6 months the cancer SIR for burn patients was 1.88 95% CI (1.40-2.52). After excluding the first six months of follow-up, the overall incidence of cancer was marginally elevated in burn patients (SIR 1.04, 95% CI 0.90-1.19, p = 0.62) and not statistically different from the incidence in comparison subjects (adjusted HR 1.03, 95% CI 0.88-1.21, p = 0.71). Conclusions: Patients that suffer burn injury have a higher incidence of cancer than the general population and a group matched by age, sex and degree of deprivation. A higher incidence of adverse health-related behaviours such as smoking, alcohol use and pre-existing health conditions among many patients that suffer a burn most likely explain this