Background The COVID-19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV). Aim This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan. Methods A cross-sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self-structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle. Results The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient-to-nurse and patient-to-doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21–28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19–26) and 28 (IQR = 23–30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (rs = 0.654, p value = .011). Similarly, 24-h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (rs = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (rs = 0.636, p value = .014). Conclusion Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels. Relevance to clinical practice Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non-compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.

Each year, approximately 70 million people suffer traumatic brain injury, which has a significant physical, psychosocial and economic impact for patients and their families. It is recommended in the UK that all patients with traumatic brain injury and a Glasgow coma scale ≤ 8 should be transferred to a neurosurgical centre. However, many patients, especially those in whom neurosurgery is not required, are not treated in, nor transferred to, a neurosurgical centre. This review aims to provide clinicians who work in non-neurosurgical centres with a summary of contemporary studies relevant to the critical care management of patients with traumatic brain injury. A targeted literature review was undertaken that included guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials (published in English between 1 January 2017 and 1 July 2022). Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also eligible for inclusion. Analysis of the topics identified during the review was then summarised. These included: fundamental critical care management approaches (including ventilation strategies, fluid management, seizure control and osmotherapy); use of processed electroencephalogram monitoring; non-invasive assessment of intracranial pressure; prognostication; and rehabilitation techniques. Through this process, we have formulated practical recommendations to guide clinical practice in non-specialist centres.

Background: Radial arterial catheters are frequently used for monitoring and blood sampling in critical care patients. Ischaemic complications are rare but can cause significant morbidity. The use of vascular ultrasound in critical care is becoming increasingly commonplace. This service evaluation aims to assess the feasibility of training novices in advanced vascular ultrasound assessment, prior to radial arterial cannulation. Methods: Over a 4-month period, data was collected from patients admitted to the intensive care unit at the William Harvey Hospital, Ashford, Kent. Ultrasound was used to assess for the presence, size and flow of the radial and ulnar arteries. The assessments were performed by two novice residents in intensive care, who were trained in advanced ultrasound assessment of the radial and ulnar arteries, by an intensive care consultant with expertise in vascular ultrasound. Results: One hundred and five limbs were assessed in 53 patients. Novices were deemed to be sufficiently competent, after performing scans on 15 patients over a 2-week period. Satisfactory images were acquired in 100% of patients. The most common finding was a small diameter ulnar artery, present in 30 limbs (29%), while only 1 patient (1%) was found to have an absent ulnar artery. Thirty-two limbs had a radial arterial catheter in-situ. There were no ischaemic complications. Conclusion: This service evaluation demonstrates that the training of novices in advanced ultrasound assessment of the radial and ulnar arteries by an intensive care consultant, is feasible. Moreover, this modality may identify patients at risk of critical limb ischaemia. This particular investigation may be considered for incorporation into existing vascular ultrasound assessments.

Shock is a common and deadly illness with a dynamic course over time. Echocardiography is an essential diagnostic tool in the management of shock. Each phase of shock management requires a specific approach with different echocardiographic goals. The initial goal of echocardiography is to diagnose the cause of shock, followed by treatment optimization, stabilization, and deescalation. The initial examination is rapid and based on the recognition of patterns (low mean systemic pressure, left and right heart failure, tamponade, and catastrophic valve failure) using a qualitative 2-dimensional examination with selected Doppler techniques. Subsequent examinations are often more detailed, semiquantitative, and quantitative.

Background There are concerns that airway management in patients with suspected or confirmed cervical spine injury may exacerbate an existing neurological deficit, cause a new spinal cord injury or be hazardous due to precautions to avoid neurological injury. However, there are no evidence-based guidelines for practicing clinicians to support safe and effective airway management in this setting. Methods An expert multidisciplinary, multi-society working party conducted a systematic review of contemporary literature (January 2012–June 2022), followed by a three-round Delphi process to produce guidelines to improve airway management for patients with suspected or confirmed cervical spine injury. Results We included 67 articles in the systematic review, and successfully agreed 23 recommendations. Evidence supporting recommendations was generally modest, and only one moderate and two strong recommendations were made. Overall, recommendations highlight key principles and techniques for pre-oxygenation and facemask ventilation; supraglottic airway device use; tracheal intubation; adjuncts during tracheal intubation; cricoid force and external laryngeal manipulation; emergency front-of-neck airway access; awake tracheal intubation; and cervical spine immobilisation. We also signpost to recommendations on pre-hospital care, military settings and principles in human factors. Conclusions It is hoped that the pragmatic approach to airway management made within these guidelines will improve the safety and efficacy of airway management in adult patients with suspected or confirmed cervical spine injury.

Purpose Echocardiography is recommended as a first-line tool in the assessment of patients with shock. The current provision of echocardiography in critical care is poorly defined. The aims of this work were to evaluate the utilisation of echocardiography in patients presenting to critical care with shock, its impact on decision making, and adherence to governance guidelines. Methods We conducted a prospective, multi-centre, observational study in 178 critical care units across the United Kingdom (UK) and Crown Dependencies, led by the UK’s Trainee Research in Intensive Care Network. Consecutive adult patients (≥ 18 years) admitted with shock were followed up for 72 h to ascertain whether they received an echocardiogram, the nature of any scan performed, and its effect on critical treatment decision making. Results 1015 patients with shock were included. An echocardiogram was performed on 545 (54%) patients within 72 h and 436 (43%) within 24 h of admission. Most scans were performed by the critical care team (n = 314, 58%). Echocardiography was reported to either reduce diagnostic uncertainty or change management in 291 (54%) cases. Patients with obstructive or cardiogenic shock had their management altered numerically more often by echocardiography (n = 15 [75%] and n = 100 [58%] respectively). Twenty-five percent of echocardiograms performed adhered to current national governance and image storage guidance. Conclusion Use of echocardiography in the assessment of patients with shock remains heterogenous. When echocardiography is used, it improves diagnostic certainty or changes management in most patients. Future research should explore barriers to increasing use of echocardiography in assessing patients presenting with shock.

Training for doctors, and other healthcare workers, has traditionally focussed on developing the knowledge and technical skills relevant to individual specialties. There has been an assumption that once trained in this way, we will be able to work easily and effectively in teams with other professionals. Multidisciplinary working is now a normal pattern of healthcare delivery and teamwork is taught as part of current curricula. Interdisciplinary learning is becoming more common, with medical students, nursing students and other professions allied to medicine learning together during their training. Healthcare staff who are already qualified have not had the benefit of being taught the particular skills needed to work well as part of diverse teams, nor given the skills to identify and overcome barriers to effective teamwork. We all need to develop these skills to help our patients get the best care from the teams looking after them.

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.