Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

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International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC)

Evaluation of out-of-hospital cardiac arrest using transesophageal echocardiography in the emergency department

Tuberculous meningitis is the most severe form of tuberculosis and often causes critical illness with high mortality. Two primary management objectives are reducing intracranial pressure, and optimising cerebral perfusion, while killing the bacteria and controlling intracerebral inflammation. However, the evidence base guiding the care of critically ill patients with tuberculous meningitis is poor and many patients do not have access to neurocritical care units. Invasive intracranial pressure monitoring is often unavailable and although new non-invasive monitoring techniques show promise, further evidence for their use is required. Optimal management regimens of neurological complications (eg, hydrocephalus and paradoxical reactions) and of hyponatraemia, which frequently accompanies tuberculous meningitis, remain to be elucidated. Advances in the field of tuberculous meningitis predominantly focus on diagnosis, inflammatory processes, and antituberculosis chemotherapy. However, clinical trials are required to provide robust evidence guiding the most effective supportive, therapeutic, and neurosurgical interventions for tuberculous meningitis that will improve morbidity and mortality.

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The neurocritical care of tuberculous meningitis

OBJECTIVES:
Clear understanding of the long-term consequences of critical care survivorship is essential. We investigated the care process and individual factors associated with long-term mortality among ICU survivors and explored hospital use in this group.

DESIGN:
Population-based data linkage study using the Secure Anonymised Information Linkage databank.

SETTING:
All ICUs between 2006 and 2013 in Wales, United Kingdom.

PATIENTS:
We identified 40,631 patients discharged alive from Welsh adult ICUs.

INTERVENTIONS:
None.

MEASUREMENTS AND MAIN RESULTS:
Primary outcome was 365-day survival. The secondary outcomes were 30- and 90-day survival and hospital utilization in the 365 days following ICU discharge. Kaplan-Meier curves were plotted to compare survival rates. Cox proportional hazards regression models were used to determine risk factors of mortality. Seven-thousand eight-hundred eighty-three patients (19.4%) died during the 1-year follow-up period. In the multivariable Cox regression analysis, advanced age and comorbidities were significant determinants of long-term mortality. Expedited discharge due to ICU bed shortage was associated with higher risk. The rate of hospitalization in the year prior to the critical care admission was 28 hospitalized days/1,000 d; post critical care was 88 hospitalized days/1,000 d for those who were still alive; and 57 hospitalized days/1,000 d and 412 hospitalized days/1,000 d for those who died by the end of the study, respectively.

CONCLUSIONS:
One in five ICU survivors die within 1 year, with advanced age and comorbidity being significant predictors of outcome, leading to high resource use. Care process factors indicating high system stress were associated with increased risk. More detailed understanding is needed on the effects of the potentially modifiable factors to optimize service delivery and improve long-term outcomes of the critically ill.

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Risk Factors for 1-Year Mortality and Hospital Utilization Patterns in Critical Care Survivors: A Retrospective, Observational, Population-Based Data Linkage Study.

Importance The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. Objective To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. Design, Setting, and Participants Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. Exposures Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. Main Outcomes and Measures The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. Results Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years;P  Conclusions and Relevance The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.

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Assessment of the Safety of Discharging Select Patients Directly Home From the Intensive Care Unit: A Multicenter Population-Based Cohort Study.

In the unconscious patient, there is a diagnostic void between the neurologic physical exam, and more invasive, costly and potentially harmful investigations. Transcranial color-coded sonography and two-dimensional transcranial Doppler imaging of the brain have the potential to be a middle ground to bridge this gap for certain diagnoses. With the increasing availability of point-of-care ultrasound devices, coupled with the need for rapid diagnosis of deteriorating neurologic patients, intensivists may be trained to perform point-of-care transcranial Doppler at the bedside. The feasibility and value of this technique in the intensive care unit to help rule-in specific intra-cranial pathologies will form the focus of this article. The proposed scope for point-of-care transcranial Doppler for the intensivist will be put forth and illustrated using four representative cases: presence of midline shift, vasospasm, raised intra-cranial pressure, and progression of cerebral circulatory arrest. We will review the technical details, including methods of image acquisition and interpretation. Common pitfalls and limitations of point-of-care transcranial Doppler will also be reviewed, as they must be understood for accurate diagnoses during interpretation, as well as the drawbacks and inadequacies of the modality in general.

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Point-of-care transcranial Doppler by intensivists

Objectives:To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteri...

Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units—A Direct From ICU Sent Home Study:

Diagnostic Accuracy of Critical Care Transesophageal Echocardiography vs Cardiology-Led Echocardiography in ICU Patients

Objective:Critical care echocardiography has become an integral tool in the assessment and management of critically ill patients Critical care transesophageal echocardiography (TEE) offers diagnos

Impact of Critical Care Transesophageal Echocardiography in Medical-Surgical ICU Patients: Characteristics and Results From 274 Consecutive Examinations.

BackgroundInflammation and oxidative damage caused by severe infections may be attenuated by vitamin C.MethodsWe conducted a systematic review of randomized controlled trials (RCTs) of parenteral vitamin C as combined therapy or monotherapy versus no parenteral vitamin C administered to adults hospitalized with severe infection. The primary outcome was mortality. We performed random-effects meta-analyses and assessed certainty in effect estimates.ResultsOf 1547 citations, 41 RCTs (n = 4915 patients) were eligible for inclusion. Low-certainty evidence suggested that vitamin C may reduce in-hospital mortality (21 RCTs, 2762 patients; risk ratio, 0.88 [95% confidence interval (CI), 0.73 to 1.06]), 30-day mortality (24 RCTs, 3436 patients; risk ratio, 0.83 [95% CI, 0.71 to 0.98]), and early mortality (before hospital discharge or 30 days; 34 RCTs, 4366 patients; risk ratio, 0.80 [95% CI, 0.68 to 0.93]). Effects were attenuated in sensitivity analyses limited to published blinded trials at low risk-of-bias (in-hospital mortality: risk ratio, 1.07 [95% CI, 0.92 to 1.24], moderate certainty; 30-day mortality: risk ratio, 0.88 [95% CI, 0.71 to 1.10], low certainty; and early mortality: risk ratio, 0.88 [95% CI, 0.73 to 1.06], low certainty). For 90-day mortality, all trials had low risk-of-bias; moderate-certainty evidence suggested harm (five RCTs, 1722 patients; risk ratio, 1.07 [95% CI, 0.94 to 1.21]). Moderate-certainty evidence suggested an increased risk of hypoglycemia (risk ratio, 1.20 [95% CI, 0.69 to 2.08]). Effects on other secondary outcomes were mixed and informed by low-certainty evidence. No credible subgroup effects were observed for mortality related to cointerventions (monotherapy vs. combined therapy), dose, or type of infection (Covid-19 vs. other).ConclusionsOverall, evidence from RCTs does not establish a survival benefit for vitamin C in patients with severe infection. (PROSPERO number, CRD42020209187.) 

Vincent I Lau

Papers

Point-of-care transcranial Doppler by intensivists

Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units—A Direct From ICU Sent Home Study:

Diagnostic Accuracy of Critical Care Transesophageal Echocardiography vs Cardiology-Led Echocardiography in ICU Patients

Impact of Critical Care Transesophageal Echocardiography in Medical-Surgical ICU Patients: Characteristics and Results From 274 Consecutive Examinations.

Parenteral Vitamin C in Patients with Severe Infection: A Systematic Review