January is one of our favourite times at the journal as we publish our special supplement issue of focussed reviews under the umbrella of a wider theme. This year, the theme is ‘specialist intensive care for the generalist’, and it could not come at a better time. Matt Morgan introduces the background problems tackled by the reviews in ‘Intensive care 2.0‘. One way of looking at these articles is that, whilst past supplements tended to report on what we know, this contribution, led by experts, focusses instead on uncertainties. Alas, it could be argued that 9 in 10 critical care interventions are not truly evidence-based. The second article has already attracted a lot of attention on Twitter following publication and is about patient reflections on intensive care medicine. It is written by Catherine White who had a critical illness in 2006 and has spent the last 15 years trying to make patient experience in intensive care better. There are many things we must strive to improve such as eliminating ICU delirium, but the toll of what we ask of ICU staff must also be considered.
The first of the reviews from Van Eldere and Pirani tackles the liver. They outline the principles behind how to interpret deranged liver function tests, common primary causes of liver failure in ICU, management considerations, hepatic encephalopathy, coexisting renal failure management, coagulation, gastrointestinal haemorrhage, infection and extracorporeal liver support devices. Overall however, intensive care management of liver dysfunction is largely supportive and the usual evidence-based principles of general critical care management are helpful. Wiles et al. provide up-to-date evidence on the management of traumatic brain injury in the non-neurosurgical ICU. Whilst some specialist interventions might not be available in this setting, high quality care for these patients can still be ensured by following the principles set out in this article. Tanaka Gutiez et al. discuss end of life care in ICU, including issues around ethics, limiting life-sustaining therapies, analgesia and sedation around the time of death, family discussions and the law. Some practical tips are provided on how to approach the family as well as eight end-of-life practice recommendations.
Maternity critical care is very much a developing area and this new review from Cranfield et al. tells us how to get it right (Fig. 1). It focusses on recognition of critical illness, where care should be delivered, critical care strategies, timing of birth, teamworking and implications for resource limited settings. There is an urgent need here for the evidence base to catch up with other areas of intensive care medicine. Following on from the recent pandemic, our knowledge of how to treat respiratory viral infections in ICU is no doubt much improved. Conway Morris and Smielewska provide everything we need to know about this as well as other viral infections such as those that are blood-borne, enteric, reactivated and unusual/rare. The only certainty is that viruses will continue to wreak havoc in ICUs for years to come given the effects of climate change, habitat invasion and global interconnectedness.
Figure 1 Benefits and compromises associated with different locations for maternity critical care. PET, pre-eclampsia; MEOWs, maternal early obstetric warning scores.
Most of us think we know about acute kidney injury and renal medicine in ICU, and this review from Boyer et al. tackles all the usual areas but also discusses the emerging role of the nephrologist in the ICU. There is much left to study, including peri-operative biomarker-guided interventions, which promise to improve postoperative outcomes in patients who might have in the past developed a more severe acute kidney injury. Renal disease in ICU is common, and there are many areas where we can improve care for patients today. Finally, Pisciotta et al. discuss the intricacies of diagnosis in the ICU (Fig. 2). In a world with increasing availabilities of ‘tests’, they emphasise the importance instead of bedside clinical examination and spending time with the patient.
Figure 2 The diagnostic process and metacognition. Diagnostic process phases (in blue) are interspersed with metacognitive timeouts (in orange).
The February issue is also now available online and the first paper is the largest of its kind to look for an association between prenatal exposure to anaesthesia and impaired neurodevelopmental outcomes. They included the parents of 129 exposed and 453 unexposed children and conclude that, in the general population, prenatal exposure to anaesthesia for non-obstetric surgery is not associated with clinically meaningful impairments in neurodevelopmental outcomes (Fig. 3). In the associated editorial, Kearns et al. provide some practical considerations for non-obstetric surgery in the pregnant patient. It sets the new paper by Bleeser et al. in the context of previous related research. Overall, they argue that these new data provide further reassurance for parents and healthcare staff in what remains an area that has been under-researched.
Figure 3 Primary and secondary outcomes. Diamonds and error bars represent the estimate for the mean difference of t-scores (exposed minus unexposed) and their 95%CIs. Inverse probability of treatment weighting (panel a) was used to reduce bias by confounders. In the sensitivity analyses, other methods to reduce bias by confounders were used (panels b and c). Data were also analysed without taking confounders into account (panel d). BRIEF, Behavior Rating Inventory of Executive Function; CBC, Child Behavior Checklist.
Previously we published articles on aerosol generating procedures and fasting before surgery. This month, we have two important editorials on these topics. Checketts reminds us how multiple hospitals have turned the relationship between fluid fasting and safety in anaesthetic practice on its head. It seems that this is a good example of where guidelines have not kept pace with clinical practice. Speaking of which, Harrison et al. discuss the interface between research, guidance and implementation for aerosol-generating procedures. They list the changes in NHS England guidance occurring between January–May 2020 and then the final version in June 2022.
Elsewhere we have: a randomised non-inferiority trial of ultrasound-guided genicular nerve blockade vs. local infiltration analgesia for total knee arthroplasty; a review of anaesthesia for vascular emergencies; and a review of the management of thoracic trauma. This month’s Reviewer Recommendations includes guides to conducting a Delphi consensus process and collaborative research studies.
As we return from a fantastic Winter Scientific Meeting in London, it is worth reflecting on our highlights, which include the launch of new human factors guidelines, a summary of our new ICU special issue, presentation of early NAP7 data and a live trauma simulation. We managed to catch Dr Fiona Kelly for a quick summary of her new guidelines, which you can now enjoy for free, here.
Mike Charlesworth and Andrew Klein