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B H Cuthbertson

Publications and source records attributed to B H Cuthbertson.

At least 19 recordsLinked to original sources
PubMed2006

Non-technical skills in the intensive care unit.

In high-risk industries such as aviation, the skills not related directly to technical expertise, but crucial for maintaining safety (e.g. teamwork), have been categorized as non-technical skills. Recently, research in anaesthesia has identified and developed a taxonomy of the non-technical skills requisite for safety in the operating theatre. Although many of the principles related to performance and safety within anaesthesia are relevant to the intensive care unit (ICU), relatively little research has been done to identify the non-technical skills required for safe practice within the ICU. This review focused upon critical incident studies in the ICU, in order to examine whether the contributory factors identified as underlying the critical incidents, were associated with the skill categories (e.g. task management, teamwork, situation awareness and decision making) outlined in the Anaesthetists' Non-technical Skills (ANTS) taxonomy. We found that a large proportion of the contributory factors underlying critical incidents could be attributed to a non-technical skill category outlined in the ANTS taxonomy. This is informative both for future critical incident reporting, and also as an indication that the ANTS taxonomy may provide a good starting point for the development of a non-technical skills taxonomy for intensive care. However, the ICU presents a range of unique challenges to practitioners working within it. It is therefore necessary to conduct further non-technical skills research, using human factors techniques such as root-cause analyses, observation of behaviour, attitudinal surveys, studies of cognition, and structured interviews to develop a better understanding of the non-technical skills important for safety within the ICU. Examples of such research highlight the utility of these techniques.

Attitude of Health Personnel↗
PubMed2006

A national survey of intensive care follow-up clinics.

Intensive care follow-up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow-up clinics in the UK is unknown. We performed a survey of intensive care follow-up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow-up clinics and details of current follow-up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow-up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow-up clinic, 158 (88%) cited 'financial constraints' as the reason. Over half of the follow-up clinics (44 clinics, 55%) were nurse-led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow-up clinics (39 clinics, 49%) have pre-negotiated access to at least one other out-patient service.

Critical Care↗
PubMed2005

B-type natriuretic peptide and the prediction of outcome in patients admitted to intensive care.

B-type natriuretic peptide is known to predict outcome in congestive cardiac failure and myocardial infarction. We aimed to determine whether measurement of B-type natriuretic peptide would predict hospital mortality in patients admitted to an intensive care unit. We conducted a prospective observational cohort study in 78 consecutive patients. Demographics, clinical details and clinical outcomes were recorded. Admission and 24 h B-type natriuretic peptide and cardiac troponin I levels were measured. B-type natriuretic peptide and cardiac troponin I levels taken on intensive care admission and 24 h after admission did not accurately predict hospital mortality for all patients, including patients with severe sepsis or septic shock (all p > 0.05). B-type natriuretic peptide levels were higher in patients with severe sepsis and septic shock (p = 0.02), in patients > or = 65 years (p = 0.04) and in patients with raised creatinine > or = 110 micromol.l(-1) (p = 0.02). We concluded that B-type natriuretic peptide, measured soon after admission to intensive care, does not usefully predict outcome after intensive care.

APACHE↗
PubMed2005

Quality of life before and after intensive care.

Quality of life is often thought to be poor before and after intensive care unit admission. The aim of this study was to investigate changes in quality of life before and after intensive care. A prospective cohort study of 300 consecutive patients admitted to intensive care was performed in a Scottish Teaching Hospital. Quality of life was assessed premorbidly and 3, 6 and 12 months after intensive care admission for surviving patients using SF-36 as well as EQ-5D scores at 12 months. The median value for age was 60.5 years and for APACHE II score, 18. The mean length of stay was 6.7 days. SF-36 physical component scores decreased from premorbid values at 3 months (p = 0.05) and then returned to premorbid values at 12 months (p < 0.001). The mean physical scores were below the population norm at all time points but the mean mental scores were similar or higher than these population norms. Patients who died after intensive care discharge had lower quality of life scores than did survivors (all p < 0.01). Poor premorbid quality of life was demonstrated and appears to reduce after ICU discharge. For survivors there was a slow increase in physical quality of life to premorbid levels by the end of the first year but these remained lower than in the general population. ICU patients experience a considerable longer-term burden of ill health.

APACHE↗
PubMed2005

Clinical effectiveness and cost-effectiveness of drotrecogin alfa (activated) (Xigris) for the treatment of severe sepsis in adults: a systematic review and economic evaluation.

OBJECTIVES: To assess the clinical and cost-effectiveness of drotrecogin alfa (activated) for the treatment of adults with severe sepsis in a UK context. DATA SOURCES: Electronic databases. Data from the commercial use of the drug up to April 2002. Data from the manufacturer submission to the National Institute for Clinical Excellence (NICE). REVIEW METHODS: A systematic review of the literature and an economic evaluation were undertaken. Data were synthesised through a narrative review with full tabulation of results from included studies. RESULTS: The evidence on the effectiveness of drotrecogin alfa (activated) for the treatment of severe sepsis came primarily from one large pivotal randomised controlled trial, the PROWESS study. This study demonstrated a statistically significant absolute reduction in 28-day mortality of 6.5%. Longer term survival benefit was maintained to 90 days. By 9 months, the trend towards increased median survival was non-significant, although the survival curves did not cross. Results presented by the number of organ dysfunctions were not statistically significant, but when mortality rates for those with two or more organ failures were combined, the relative risk of death was significantly lower in those treated with drotrecogin alfa (activated) compared with placebo. However, this report highlights a number of considerations relevant to the subgroup analyses reported for the PROWESS study. Published cost-effectiveness studies of treatment with drotrecogin alfa (activated) have applied a range of methods to the estimation of benefits, estimating an incremental gain per treated patient of between 0.38 and 0.68 life-years (for patients with severe sepsis). For patients with severe sepsis and multiple organ dysfunction, the manufacturer (Eli Lilly) estimated an incremental gain of 1.115 life-years per treated patient, compared to 1.351 life-years per treated patient estimated by the Southampton Health Technology Assessments Centre (SHTAC). These latter UK analyses are based on a patient group that is more severely affected by disease, where effectiveness is greater and the baseline risk of all-cause mortality is much higher (SHTAC analysis), these factors are associated with the noted difference in effect. The three published cost-effectiveness studies report cost for US and Canadian patient groups; for those patients with severe sepsis they report the additional cost per patient treated in a range around 10,000-16,000 dollars. The manufacturer's submission reports analysis for the UK, based on 28-day survival data in patients with severe sepsis and multiple organ dysfunction (the European licence indication), with the additional mean cost per treated patient estimated to be 5106 pounds. The analysis undertaken by SHTAC, for a UK group of patients with severe sepsis and multiple organ dysfunction, estimates an additional mean cost per patient treated of 6661 pounds. The manufacturer's submission to NICE presents cost-effectiveness estimates for drotrecogin alfa (activated) in the UK, in patients with severe sepsis and multiple organ dysfunction, at 6637 pounds per quality-adjusted life-year (QALY) based on 28-day effectiveness data, and 10,937 pounds per QALY based on longer term follow-up data. SHTAC developed an independent cost-effectiveness model and estimated a base-case cost per QALY of 8228 pounds in patients with severe sepsis and multiple organ failure (based on 28-day survival data). Simulation results indicate that where the NHS is willing to pay 20,000 pounds per QALY, drotrecogin alfa (activated) is a cost-effective use of resources in 98.7% of cases. Published economic evaluations report various sensitivity analyses, with results sensitive to changes in the measure of treatment effect, but otherwise studies reported that results were robust to variations in most assumptions used in the cost-effectiveness analysis. CONCLUSIONS: Drotrecogin alfa (activated) plus best supportive care appears clinically and cost-effective compared with best supportive care alone, in a UK cohort of severe sepsis patients, and in the subgroup of more severely affected patients with severe sepsis and multiple organ failure. The introduction of drotrecogin alfa (activated) will involve a substantial additional cost to the NHS. The treatment-eligible population in England and Wales may comprise up to 16,570 patients, with an estimated annual drug acquisition cost of over 80 million pounds, excluding VAT. Further research is required on the longer term impact of drotrecogin alfa (activated) on both mortality and morbidity in UK patients with severe sepsis, on the clinical and cost-effectiveness of drotrecogin alfa (activated) in children (under 18 years) with severe sepsis, and on the effect of the timing of dosage and duration of treatment on outcomes in severe sepsis.

Adolescent↗
PubMed2004

Antibiotic-treated infections in intensive care patients in the UK.

The purpose of this audit was to study reasons for starting antibiotic therapy, duration of antibiotic treatment, reasons for changing antibiotics and the agreement between clinical suspicion and microbiological results in intensive care practice. We conducted a multicentre observational audit of 316 patients. Data on demographic details, site, treatment and nature of infection were collected. The median duration of antibiotic therapy was 7 days. Infections were community-acquired in 160 patients (55%). Antibiotics were started on clinical suspicion of infection in 237 patients (75%). Pulmonary infections were the most common, representing 52% of all proven infections. Gram-negative organisms were the most common cause of proven infections (n = 90 (50%)). The antibiotic spectrum was narrowed in light of microbiology results in 78 patients (43%) and changed due to antibiotic resistance in 38 patients (21%). We conclude that the mean duration of treatment contrasts with existing published guidelines, highlighting the need for further studies on duration and efficacy of treatment in intensive care.

Adolescent↗
PubMed2002

Exhaled nitric oxide as a marker of lung injury in coronary artery bypass surgery.

BACKGROUND: Exhaled nitric oxide (NO) concentrations have been suggested as a marker of disease onset and severity in a number of inflammatory conditions such as acute asthma. Known markers of the onset of acute lung injury require invasive tests and laboratory based analysis and have limited clinical applicability. We performed a study of the use of exhaled NO as a marker of developing acute lung injury during and after coronary artery bypass grafting in patients requiring cardiopulmonary bypass. METHODS: Mixed expired air samples were taken from the patient breathing system and analysed for exhaled NO using chemiluminescence analysis. RESULTS: Exhaled nitric oxide concentrations in expired gas correlated with the PaO2/FlO2 ratio (r = 0.23, P < 0.01). There was a non-significant trend towards a reduction in exhaled NO levels from after induction of anaesthesia to post-bypass time points, with the lowest exhaled NO concentrations occurring at this time (P = 0.07). There was no correlation between mean arterial pressure (r = -0.1, P = 0.54) or mean pulmonary artery pressure (r = -0.1. P = 0.67) and expired NO levels. CONCLUSIONS: Further work is required to test whether exhaled NO concentration may be useful in diagnosing the onset of acute lung injury in patients undergoing coronary artery bypass grafting.

Biomarkers↗
PubMed2000

Effect of inhaled nitric oxide on key mediators of the inflammatory response in patients with acute lung injury.

OBJECTIVE: Inhaled nitric oxide is used to treat hypoxia associated with acute lung injury. Endogenous nitric oxide regulates inflammatory responses, but the effect of inhaled nitric oxide therapy is unknown. We hypothesized that inhaled nitric oxide may alter inflammatory responses and endogenous nitric oxide synthase activity. DESIGN: A randomized, prospective interventional study. SETTING: A university hospital's general intensive care unit. PATIENTS: Thirty-two patients with acute lung injury. INTERVENTIONS: Patients who responded to test doses of nitric oxide were randomized to ventilator therapy with and without inhaled nitric oxide. The inhaled concentration of nitric oxide was determined by dose titration at 0, 2, 10, and 40 ppm and the minimum concentration used, which resulted in an increase in the PaO2/FIO2 ratio of at least 25%. MEASUREMENTS AND MAIN RESULTS: Patients were followed up for 30 days or until death, and bronchoalveolar lavage (BAL) was performed at 0, 24, and 72 hrs. Nitric oxide synthase activity was measured spectrophotometrically, and myeloperoxidase, elastase, interleukin-8, and leukotrienes were measured in BAL fluid by enzyme immunoassay. Total nitrite and lipid peroxides in serum were measured colorimetrically. Nitric oxide synthase activity decreased (p = .01) and total nitrite increased (p = .02) in patients receiving inhaled nitric oxide. Other markers of inflammation in BAL fluid did not change. Lipid peroxide concentrations also did not alter. CONCLUSIONS: The decrease in activity of nitric oxide synthase in patients receiving nitric oxide is likely to be the result of feedback inhibition of the enzyme. This study shows that inhaled nitric oxide has no effect on several markers of the inflammatory response system and does not lead to increased oxidant stress.

Acute Disease↗
PubMed1999

Inhaled nitric oxide.

Explore the source record for details and available documents.

Administration, Inhalation↗
PubMed1999

The role of the intensive care unit in the management of the critically ill surgical patient.

Surgical patients make up 60-70% of the work load of intensive care units in the UK. There is a recognised short fall in the resource allocation for high dependency units (HDUs) and intensive care units (ICUs) in this country, despite repeated national audits urging that this resource be increased. British ICUs admit patients later and with higher severity of illness scores than elsewhere and this leads to higher ICU mortality. How can this situation be improved? Scoring systems that allow selection of appropriate patients for admission to ICU and avoid inappropriate admission are still in development. Pre-operative admission and optimisation in ICU is rare in this country despite increasing evidence to support this practice in high risk surgical patients. Early admission to ICU, with potential improvement in outcomes, could also be achieved using multi-disciplinary medical emergency teams. These teams would be alerted by ward staff in response to set specific conditions and physiological criteria. These proposals are still under trial but may offer benefit by reducing mortality in critically ill surgical patients.

Critical Illness↗
PubMed1998

The effect of nitric oxide and peroxynitrite on apoptosis in human polymorphonuclear leukocytes.

In acute lung injury, neutrophil apoptosis may be important in regulating the inflammatory process by controlling neutrophil numbers and thus activity. Exogenous inhaled nitric oxide is now a widely used therapy in patients with acute lung injury, and its effects on apoptosis may be important. We investigated the effect of nitric oxide and peroxynitrite on apoptosis in lipopolysaccharide stimulated polymorphonuclear leukocytes as a model of nitric oxide-treated lung injury. Cells were incubated for up to 16 h with and without 1.7 microg/ml lipopolysaccharide and the nitric oxide donor GEA-3162 or the peroxynitrite donor SIN-1. Apoptosis was assessed using flow cytometry following annexin-V staining, after 4, 6, 8, and 16 h. Data were assessed using Kruskal-Wallis analysis of variance or Mann-Whitney U-test as appropriate. Annexin-V staining increased spontaneously over 16 h in untreated cells (p = .0002) and incubation with either 1000 microM SIN-1 or 10 microM GEA-3162 increased annexin staining at early time points in nonactivated cells. Apoptosis was attenuated when cells were exposed to lipopolysaccharide and both nitric oxide and peroxynitrite dose dependently inhibited this suppression at all time points and was most apparent at 16 h (p = .004 and .001, respectively). Exposure of activated neutrophils to exogenous nitric oxide or peroxynitrite has marked influences on apoptosis. This work has implications for the modulation of neutrophil function within the lung in patients with lung injury who receive inhaled nitric oxide therapy.

Annexin A5↗
PubMed1998

The effects of nitric oxide and peroxynitrite on interleukin-8 and elastase from lipopolysaccharide-stimulated whole blood.

UNLABELLED: Inhaled nitric oxide is now widely used in the treatment of hypoxemia and pulmonary hypertension in critically ill patients. Interleukin-8 (IL-8) and neutrophil elastase are important markers of the onset and severity of acute lung injury. We studied the effects of nitric oxide and peroxynitrite on IL-8) and elastase accumulation in lipopolysaccharide-activated whole blood. The nitric oxide donor (GEA-3162) did not affect IL-8 accumulation (P = 0.195) but did cause an increase in elastase accumulation (P = 0.007). The peroxynitrite donor (SIN-1) caused an increase in both IL-8 accumulation (P = 0.0004) and elastase accumulation (P = 0.007). The lack of effect of nitric oxide could be explained by the scavenging of nitric oxide by hemoglobin. These results suggest that modulation of the inflammatory response may occur during inhaled nitric oxide therapy in the critically ill. IMPLICATIONS: Inhaled nitric oxide, used in lung injury, reacts within the lung, forming peroxynitrite. We investigated the effect of nitric oxide and peroxynitrite on interleukin-8 and elastase release by white cells during inflammation. Nitric oxide and peroxynitrite had marked effects on elastase and interleukin-8, which suggests modulation of the inflammatory response.

Free Radical Scavengers↗