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Publications (368)
Objectives
A conservative oxygenation strategy is recommended in adult and pediatric guidelines for the management of acute respiratory distress syndrome to reduce iatrogenic lung damage. In the recently reported Oxy-PICU trial, targeting peripheral oxygen saturations (Sp o 2 ) between 88% and 92% was associated with a shorter duration of organ sup...
Background
High flow nasal cannula therapy (HFNC) and continuous positive airway pressure (CPAP) are two widely used modes of non-invasive respiratory support in paediatric critical care units. The FIRST-ABC randomised controlled trials (RCTs) evaluated the clinical and cost-effectiveness of HFNC compared with CPAP in two distinct critical care pop...
Background:
We sought to estimate whether a lower mean arterial blood pressure target, compared with a higher mean arterial blood pressure target, reduced 90-day all-cause mortality among critically ill adult patients with vasodilatory shock.
Methods:
We conducted an individual patient data meta-analysis of randomized controlled trials that eval...
Objectives
The optimal approach for resuscitation in septic shock remains unclear despite multiple randomized controlled trials (RCTs). Our objective was to investigate whether previously uncharacterized variation across individuals in their response to resuscitation strategies may contribute to conflicting average treatment effects in prior RCTs....
Background
Adiposity shows opposing associations with mortality within COVID-19 versus non-COVID-19 respiratory conditions. We assessed the likely causality of adiposity for mortality among intensive care patients with COVID-19 versus non-COVID-19 by examining the consistency of associations across temporal and geographical contexts where biases va...
Background: Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death.
Objectives
A conservative oxygenation strategy, targeting peripheral oxygen saturations (Sp o 2 ) between 88% and 92% in mechanically ventilated children in PICU, was associated with a shorter duration of organ support and greater survival compared with Sp o 2 greater than 94% in our recent Oxy-PICU trial. Sp o 2 monitors may overestimate arterial...
Background
Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes.
Methods
COAST-Nutrition was an open-label Phase...
Objectives
Management of hypotension is a fundamental part of pediatric critical care, with cardiovascular support in the form of fluids or vasoactive drugs offered to every hypotensive child. However, optimal blood pressure (BP) targets are unknown. The PRotocolised Evaluation of PermiSSive BP Targets Versus Usual CaRE (PRESSURE) trial aims to eva...
Background
In the United Kingdom, around 184,000 adults are admitted to an intensive care unit (ICU) each year with over 30% receiving mechanical ventilation. Oxygen is the commonest therapeutic intervention provided to these patients but it is unclear how much oxygen should be administered for the best clinical outcomes.
Methods
The UK-ROX trial...
Background
Healthcare-associated infections are a major cause of morbidity and mortality in critically ill children. In adults, data suggest the use of selective decontamination of the digestive tract may reduce the incidence of healthcare-associated infections. Selective decontamination of the digestive tract has not been evaluated in the paediatr...
Background
Healthcare system data (HSD) are increasingly used in clinical trials, augmenting or replacing traditional methods of collecting outcome data. This study, PRIMORANT, set out to identify, in the UK context, issues to be considered before the decision to use HSD for outcome data in a clinical trial is finalised, a methodological question p...
Rationale:
Sepsis is a frequent cause of intensive care unit (ICU) admission and mortality.
Objectives:
To evaluate temporal trends in presentation and outcomes of patients admitted to the ICU with sepsis and assess the contribution of changing case mix on outcomes.
Methods:
Retrospective cohort study of patients admitted to 261 ICUs in the Un...
Background:
The efficacy of simvastatin in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear.
Methods:
In an ongoing international, multifactorial, adaptive platform, randomized, controlled trial, we evaluated simvastatin (80 mg daily) as compared with no statin (control) in critically ill patients with Covid-19 who wer...
Background
Healthcare system data (HSD) are increasingly used in clinical trials, augmenting or replacing traditional methods of collecting outcome data. The PRIMORANT study set out to determine when HSD are of sufficient quality and utility to replace bespoke outcome data collection, a methodological question prioritised by the clinical trials com...
Background
Oxygen is the commonest intervention provided to critically ill patients requiring mechanical ventilation. Despite this, it is unclear how much oxygen should be administered to patients in order to promote the best clinical outcomes and it has been suggested that a strategy of conservative oxygen therapy (COT) may be advantageous. We the...
Importance:
Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19.
Objective:
To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19.
Design, setting, and particip...
Aims:
The incidence of in hospital cardiac arrest (IHCA) varies throughout the day. This study aimed to report the variation in incidence of IHCA, presenting rhythm and outcome based on the hour in which IHCA occurred.
Methods:
We conducted a retrospective analysis of the National Cardiac Arrest Audit (NCAA) including patients who suffered an IH...
Rationale:
Optimal systemic oxygenation targets in pediatric critical illness are unknown. A U-shaped relationship exists between blood oxygen levels and PICU mortality. Redox stress or iatrogenic injury from intensive treatments are potential mechanisms of harm from hyperoxia.
Objectives:
To measure biomarkers of oxidative status in children ad...
Background
Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associ...
Objective: To assess the causality of adiposity for mortality among patients severely ill with COVID-19 and non-COVID-19 respiratory conditions by examining the consistency of associations across temporal and geographical contexts where biases vary
Design: Prospective cohort study
Setting: 297 intensive care units (ICUs) in England, Wales, and Nort...
Purpose:
Many intensive care units (ICUs) have transitioned from systemic heparin anticoagulation (SHA) to regional citrate anticoagulation (RCA) for continuous kidney replacement therapy (CKRT). We evaluated the clinical and health economic impacts of ICU transition to RCA.
Materials and methods:
We surveyed all adult general ICUs in England an...
Background
A previous National Institute for Health and Care Research study [Harrison DA, Ferrando-Vivas P, Shahin J, Rowan KM. Ensuring comparisons of health-care providers are fair: development and validation of risk prediction models for critically ill patients. Health Serv Deliv Res 2015; 3 (41)] identified the need for more research to underst...
Introduction
This study aims to explore the impact of COVID-19 vaccination on critical care by examining associations between vaccination and admission to critical care with COVID-19 during England's Delta wave, by age group, dose, and over time.
Methods
We used linked routinely-collected data to conduct a population cohort study of patients admitt...
Aims
New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU), but the long-term impacts on patient outcomes are unclear. We compared national hospital and long-term outcomes of patients who developed NOAF in ICU with those who did not, before and after adjusting for comorbidities and ICU admission factors....
Objectives:
Oxygen administration is a fundamental part of pediatric critical care, with supplemental oxygen offered to nearly every acutely unwell child. However, optimal targets for systemic oxygenation are unknown. Oxy-PICU aims to evaluate the clinical effectiveness and cost-effectiveness of a conservative peripheral oxygen saturation (Spo2) t...
Importance:
The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known.
Objective:
To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway press...
Introduction
Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. In critically ill adults, there are data that suggest the use of Selective Decontamination of the Digestive tract (SDD), alongside standard infection control measures reduce mortality and the incidence of HCAIs. SDD-enhance...
Objectives:
To determine whether patients admitted to an ICU during times of unprecedented ICU capacity strain, during the COVID-19 pandemic in the United Kingdom, experienced a higher risk of death.
Design:
Multicenter, observational cohort study using routine clinical audit data.
Setting:
Adult general ICUs participating the Intensive Care N...
Aims
To compare in-hospital cardiac arrest (IHCA) rates and patient outcomes during the first COVID-19 wave in the United Kingdom (UK) in 2020 with the same period in previous years.
Methods
A retrospective, multicentre cohort study of 154 UK hospitals that participate in the National Cardiac Arrest Audit and have intensive care units participatin...
Background
In the UK, 10% of admissions to intensive care units receive continuous renal replacement therapy with regional citrate anticoagulation replacing systemic heparin anticoagulation over the last decade. Regional citrate anticoagulation is now used in > 50% of intensive care units, despite little evidence of safety or effectiveness.
Aim
Th...
Emerging reports of rare neurological complications associated with COVID-19 infection and vaccinations are leading to regulatory, clinical and public health concerns. We undertook a self-controlled case series study to investigate hospital admissions from neurological complications in the 28 days after a first dose of ChAdOx1nCoV-19 (n = 20,417,75...
Background
Persistent critical illness is a recognisable clinical syndrome defined conceptually as when the patient’s reason for being in the intensive care unit (ICU) is more related to their ongoing critical illness than their original reason for admission. Our objectives were: (1) to assess the day in ICU on which chronic factors (e.g., age, gen...
Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the ‘Treat’ element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been...
Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the ‘Treat’ element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been...
Objective:
To assess the association between covid-19 vaccines and risk of thrombocytopenia and thromboembolic events in England among adults.
Design:
Self-controlled case series study using national data on covid-19 vaccination and hospital admissions.
Setting:
Patient level data were obtained for approximately 30 million people vaccinated in...
Objectives:
Differences in decisions to limit life-sustaining therapy are often supported by perceptions that patients receive unnecessary and expensive treatment which provide negligible survival benefit. However, the assumption behind those beliefs-that is, that life-sustaining therapy provides no significant marginal survival benefit-remains un...
Background
New-onset atrial fibrillation (NOAF) in patients treated on an intensive care unit (ICU) is common and associated with significant morbidity and mortality. We undertook a systematic scoping review to summarise comparative evidence to inform NOAF management for patients admitted to ICU.
Methods
We searched MEDLINE, EMBASE, CINAHL, Web of...
A correction to this paper has been published: https://doi.org/10.1007/s00134-021-06413-2
Aim
To investigate how the publication of the Targeted Temperature Management (TTM) trial in December 2013 affected the trends in temperature management and outcome following admission to UK intensive care units (ICUs) after out-of-hospital cardiac arrest (OHCA).
Methods
We used a national ICU database of 1,181,405 consecutive admissions to 235 ad...
Background:
Vasopressors are administered to critical care patients to avoid hypotension, which is associated with myocardial injury, kidney injury and death. However, they work by causing vasoconstriction, which may reduce blood flow and cause other adverse effects. A mean arterial pressure target typically guides administration. An individual pa...
Rationale:
By describing trends in intensive care for patients with COVID-19 we aim to support clinical learning, service planning, and hypothesis generation.
Objectives:
To describe variation in intensive care unit (ICU) admission rates over time and by geography during the first wave of the epidemic in England, Wales and Northern Ireland; to d...
Background
Survivors of critical illness have significant psychopathological comorbidity. The treatments offered by primary health care professionals to affected patients are unstudied.
Aim
To report the psychological interventions after GPs received notification of patients who showed severe symptoms of anxiety, depression or Post-Traumatic Stres...
Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragma...
Background
The FIRST-ABC trial comprises of two pragmatic, multicentre, parallel groups, non-inferiority randomised clinical trials designed to evaluate the clinical non-inferiority of first-line use of high flow nasal cannula (HFNC) to continuous positive airway pressure (CPAP) in critically ill children who require non-invasive respiratory suppor...
Objectives:
To identify characteristics that predict 30-day mortality among patients critically ill with coronavirus disease 2019 in England, Wales, and Northern Ireland.
Design:
Observational cohort study.
Setting:
A total of 258 adult critical care units.
Patients:
A total of 10,362 patients with confirmed coronavirus disease 2019 with a s...
PurposeTo describe critical care patients with COVID-19 across England, Wales and Northern Ireland and compare them with a historic cohort of patients with other viral pneumonias (non-COVID-19) and with international cohorts of COVID-19.Methods
Extracted data on patient characteristics, acute illness severity, organ support and outcomes from the Ca...
Background
Early in a pandemic, outcomes are biased towards patients with shorter durations of critical illness. We describe 60-day outcomes for patients critically ill with confirmed COVID-19 and explore the potential bias in the weekly reported data by ICNARC.
Methods
First 200 consecutive patients with confirmed COVID-19, admitted for critical...
Background
Failure to recognise and respond to patient deterioration on hospital wards is a common cause of healthcare-related harm. If patients are not rescued and suffer a cardiac arrest as a result then only around 15% will survive. Track and Trigger systems have been introduced into the NHS to improve both identification and response to such pa...
Rationale: Examining trends in patient characteristics, processes of care and outcomes, across an epidemic, provides important opportunities for learning. Objectives: To report and explore changes in admission rates, patient characteristics, processes of care and outcomes for all patients with COVID-19 admitted to intensive care units (ICUs) in Eng...
Thrombocytopaenia is common in critically ill patients and associated with poor clinical outcomes. Current guideline recommendations for prophylactic platelet transfusions, to prevent bleeding in critically ill patients with thrombocytopaenia, are based on observational data. Recent studies conducted in non-critically ill patients have demonstrated...
Importance:
The longer-term risk of rehospitalizations and death of adult sepsis survivors is associated with index sepsis illness characteristics.
Objective:
To derive and validate a parsimonious prognostic score for unplanned rehospitalizations or death in the first year after hospital discharge of adult sepsis survivors.
Design, setting, and...
Background
The optimal airway management strategy for in-hospital cardiac arrest is unknown.
Methods
An online survey and telephone interviews with anaesthetic and intensive care trainee doctors identified by the United Kingdom Research and Audit Federation of Trainees. Questions explored in-hospital cardiac arrest frequency, grade and specialty o...
Aim: To report changes in admission rates, patient characteristics, processes of care and outcomes for all patients with COVID-19 admitted to intensive care units (ICUs) in England, Wales and Northern Ireland. Methods: Population cohort of all 10,287 patients with COVID-19 appearing in the Case Mix Programme national clinical audit from 1 February...
The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65...
Introduction
Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line...
Background
There is uncertainty about the associations of angiotensive enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) drugs with COVID-19 disease. We studied whether patients prescribed these drugs had altered risks of contracting severe COVID-19 disease and receiving associated intensive care unit (ICU) admission.
Methods
This was...
Objective
To investigate the short-term mortality effect of discharge from an intensive care unit (ICU) with a tracheostomy in place in comparison to delaying discharge until after tracheostomy removal.
Design
A propensity score matched cohort study using data from the TracMan study.
Setting
Seventy-two UK ICUs taking part in the TracMan study, a...
Aims:
The aim was to determine if the 17 June 2014 Tracey judgment regarding 'do not attempt cardiopulmonary resuscitation' decisions led to increases in the rate of in-hospital cardiac arrests resulting in a resuscitation attempt (IHCA) and/or proportion of resuscitation attempts deemed futile.
Method:
Using UK National Cardiac Arrest Audit dat...
Acute kidney injury is common in critical illness. In patients with severe acute kidney injury, renal replacement therapy is needed to prevent harm from metabolic and electrolyte disturbances and fluid overload. In the UK, continuous renal replacement therapy (CRRT) is the preferred modality, which requires anticoagulation. Over the last decade, co...
Purpose of the study
To explore whether variation in in-hospital cardiac arrest (IHCA) survival can be explained by differences in resuscitation service provision across UK acute hospitals.
Methods
We linked information on key clinical practices with patient data of adults who had a cardiac arrest on a general hospital ward or emergency admissions...
Background:
Missing data are an inevitable challenge in Randomised Controlled Trials (RCTs), particularly those with Patient Reported Outcome Measures. Methodological guidance suggests that to avoid incorrect conclusions, studies should undertake sensitivity analyses which recognise that data may be 'missing not at random' (MNAR). A recommended ap...
Objectives:
To determine whether patients admitted to an ICU during times of strain, when compared with its own norm (i.e. accommodating a greater number of patients, higher acuity of illness, or frequent turnover), is associated with a higher risk of death in ICUs with closed models of intensivist staffing.
Design:
We conducted a large, multice...
Importance
Vasopressors are commonly administered to intensive care unit (ICU) patients to raise blood pressure. Balancing risks and benefits of vasopressors is a challenge, particularly in older patients.
Objective
To determine whether reducing exposure to vasopressors through permissive hypotension (mean arterial pressure [MAP] target, 60-65 mm...
PurposeSepsis survivors have a higher risk of rehospitalisation and of long-term mortality. We assessed the rate, diagnosis, and independent predictors for rehospitalisation in adult sepsis survivors.Methods
We searched for non-randomized studies and randomized clinical trials in MEDLINE, Cochrane Library, Web of Science, and EMBASE (OVID interface...
Objectives:
We aimed to develop and validate an accurate risk prediction model for both mortality and a combined outcome of mortality and morbidity for maternal admissions to critical care.
Design:
We used data from a high-quality prospectively collected national database, supported with literature review and expert opinion. We tested univariabl...
Objectives:
Major increases in the proportion of elderly people in the population are predicted worldwide. These population increases, along with improving therapeutic options and more aggressive treatment of elderly patients, will have major impact on the future need for healthcare resources, including critical care. Our objectives were to explor...
[Objective] To determine associations between important pre-arrest and intra-arrest prognostic factors and survival after in-hospital cardiac arrest.
[Design] Systematic review and meta-analysis.
[Data Sources] Medline, PubMed, Embase, Scopus, Web of Science, and the Cochrane Database of Systematic Reviews from inception to 4 February 2019. Prima...
Abstract Background Fever improves pathogen control at a significant metabolic cost. No randomized clinical trials (RCT) have compared fever treatment thresholds in critically ill children. We performed a pilot RCT to determine whether a definitive trial of a permissive approach to fever in comparison to current restrictive practice is feasible in...
Background
Methicillin-Resistant Staphylococcus aureus (MRSA) and C. difficile infection have reduced across the UK National Health Service in the last decade following implementation of an infection control campaign. The national impact on hospital-acquired infections in the ICU however has not been comprehensively documented.
Methods
Data on MRS...
Background:
Factors influencing outcome after Critical Care Unit (CCU) for patients with status epilepticus (SE) are poorly understood. We examined survival for these patients to establish (a) whether the risk of mortality has changed over time and (b) whether admission to different unit types affects mortality risk over and above other risk facto...
Background:
Staphylococcus aureus (S. aureus) can cause secondary infection in eczema, and may promote inflammation in eczema that does not look infected. There is no standard intervention to reduce S. aureus burden in eczema. It is unclear whether antimicrobial treatments help eczema or promote bacterial resistance. This is an update of a 2008 Co...
Vasodilatory shock is common in critically ill patients and vasopressors are a mainstay of therapy. A meta-analysis suggested that use of a higher, as opposed to a lower, mean arterial pressure target to guide titration of vasopressor therapy, could be associated with a higher risk of death in older critically ill patients. The 65 trial is a pragma...
The authors of the article entitled “Paediatric Intensive Care admission blood pressure and risk of death in 30,334 children” inform that due to an error in their database extraction, the following corrections to the data published should be notified.
Objective
To assess family satisfaction with intensive care units (ICUs) in the UK using the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire, and to investigate how characteristics of patients and their family members impact on family satisfaction.
Design
Prospective cohort study nested within a national clinical a...
Background
High numbers of patients experience severe acute stress in critical care units. Acute stress has been linked to post-critical care psychological morbidity, including post-traumatic stress disorder (PTSD). Previously, a preventive, complex psychological intervention [Psychological Outcomes following a nurse-led Preventative Psychological...
Background:
Methicillin-Resistant Staphylococcus aureus (MRSA) and C. difficile infection have reduced across the UK National Health Service in the decade following implementation of an infection control campaign. The national impact on hospital-acquired infections due to other organisms has not been documented.
Methods:
Data on MRSA, C. diffici...
The 65 trial is a pragmatic, multicentre, parallel-group, open-label, randomised clinical trial of permissive hypotension (targeting a mean arterial pressure target of 60–65 mmHg during vasopressor therapy) versus usual care in critically ill patients aged 65 years or over with vasodilatory hypotension. The trial will recruit 2600 patients from 65...
Background:
Geographical variation is observed in invasive candida infection (ICI) and differences between critical care units (CCUs) may contribute.
Objectives:
To examine rates, risk factors and individual and unit level variation of ICI in UK CCUs.
Methods:
Data from the Fungal Infection Risk Evaluation Study was used to examine individuals...
Aim:
Cerebral Performance Category (CPC) can be used to categorise neurological outcome after cardiac arrest. There is no consensus on what information sources can be used to derive the CPC. This study describes the information sources used by hospitals participating in the UK National Cardiac Arrest Audit (NCAA) and their impact on the CPC report...
Importance
Sepsis survivors, defined as adult patients who survived to hospital discharge following a critical care unit admission for sepsis, are at increased risk of long-term mortality. Identifying factors independently associated with long-term mortality, known during critical care admission for sepsis, could inform targeted strategies to reduc...
Background
Fever accelerates host immune system control of pathogens but at a high metabolic cost. The optimal approach to fever management and the optimal temperature thresholds used for treatment in critically ill children are unknown.
Objectives
To determine the feasibility of conducting a definitive randomised controlled trial (RCT) to evaluat...
