Simon Jonathan Finney

Barts Health NHS Trust

Background Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO duri...

Background: Extracorporeal membrane oxygenation (ECMO) has been widely used in patients with COVID-19, but uncertainty remains about the determinants of in-hospital mortality and data on post-discharge outcomes are scarce. The aims of this study were to investigate the variables associated with in-hospital outcomes in patients who received ECMO dur...

Background COVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-1...

Background Out-of-hospital cardiac arrest carries a poor prognosis with survival less than 10% in many patient cohorts. Survival is inversely associated with duration of resuscitation as external chest compressions do not provide sufficient blood flow to prevent irreversible organ damage during a prolonged resuscitation. Extracorporeal membrane oxy...

In 2013, a group of clinicians on behalf of the National Institute for Health Research, collaborated with ICU Steps to produce guidance about people being enrolled in more than one critical care trial. This is referred to as “co-enrolment” and can be where a person takes part in one study at the same time as another study (or one after the other in...

Introduction Designated cross-specialty shock teams have been proposed as a mechanism to manage the complexity of decision-making and facilitate collaborative, patient-centred care-planning in cardiogenic shock. Observational data support the notion that shock protocols and teams may improve survival, but there is an absence of data interrogating h...

Introduction: Simulation-based learning and hands-on learning are popular in medicine, particularly in areas where life-saving manoeuvres and team skills are required. Simulations can be provided in different environments: directly in hospitals (in situ), in dedicated facilities (simulation rooms) or, on occasion, at scientific meetings, thus takin...

Acute respiratory failure is defined clinically by hypoxaemia with (type 2) or without (type 1) hypercapnia. It is one of the most common problems afflicting critically ill patients and is a common indication for transfer to an intensive care unit. Critical illness may be manifest solely as respiratory insufficiency, especially in patients with cov...

A 43-year-old man with Austrian syndrome, the triad of infective endocarditis (IE), pneumonia and meningitis caused by Streptococcus pneumoniae , underwent emergency aortic and mitral valve replacement and closure of an aortic root abscess. Postoperatively, he required mechanical circulatory support with veno-arterial extracorporeal membrane oxygen...

Around 2% of adults have heart failure, and the prevalence increases with advancing ages. This may manifest chronically but also acutely. Cardiogenic shock is the most extreme manifestation of acute heart failure, manifesting as the rapid development of life-threatening tissue hypoperfusion and organ dysfunction. The causes and management of these...

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) is an internationally recognised treatment for refractory cardiac arrest, with evidence of improved outcomes in selected patient groups from cohort studies and case series. In order to establish the clinical need for an in-hospital extracorporeal cardiopulmonary resuscitation servic...

The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilatio...

Introduction: The probability of surviving a cardiac arrest remains low. International resuscitation guidelines state that extracorporeal cardiopulmonary resuscitation (ECPR) may have a role in selected patients suffering refractory cardiac arrest. Identifying these patients is challenging. This project systematically reviewed the evidence compari...

Every year, about one in every four people die of heart disease in the United States. The most common condition is coronary artery disease and its sequelae of myocardial infarction, cardiac arrest and heart failure. As the population ages, structural heart disease, particularly of the aortic and mitral valves, becomes ever more prevalent. Indeed, h...

Core Topics in Cardiothoracic Critical Care - edited by Kamen Valchanov July 2018

Introduction: Comprehensive clinical examination can be compromised in patients on veno-venous extracorporeal membrane oxygenation (VV-ECMO). Adjunctive diagnostic imaging strategies range from bedside imaging only to routine computed tomography (CT). The risk-benefit of either approach remains to be evaluated. Patients retrieved to the Royal Brom...

One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lun...

This chapter introduces some of the main concepts and challenges associated with the design and development of large offshore DC systems. Various engineering, regulatory, and economic issues associated with offshore networks are described. Different converter topologies, and offshore DC grid configurations and control strategies are discussed. Syst...

Large offshore wind farms require extensive sub-sea cables within the collection network. Present solutions are based around medium-voltage AC collection networks. Recent studies have highlighted the potential benefits of DC collection networks. However, achieving DC/DC conversion at the required voltage and power levels presents a significant chal...

DC-AC rectifiers with reduced numbers of switches, in order to reduce cost, weight, volume and switching losses (especially for low-power applications), have been presented and discussed in the literature. These converters are less exposed to semiconductor switch damage and exhibit lower common-mode currents. However, they have several disadvantage...

Introduction and objectives Patients with pulmonary hypertension (PH) represent an extremely high-risk surgical group, with previous reported mortality 7–18%, and predicting perioperative risk is difficult. The aim of this study was to characterise a current cohort of patients with pulmonary hypertension undergoing surgery in a National UK Designat...

In the intensive care unit (ICU), satisfaction with the care of their loved one impacts upon family members' psychological morbidity and maybe the health of patients afterwards. Enhancing family satisfaction is holistic and may impact on health throughout the hospital and beyond.

Objective: Endothelial dysfunction associated with systemic inflammation can contribute to organ injury/failure following cardiac surgery requiring cardiopulmonary bypass (CPB). Roundabout protein 4 (Robo4), an endothelial-expressed transmembrane receptor and regulator of cell activation, is an important inhibitor of endothelial hyper-permeability...

Extracorporeal membrane oxygen (ECMO) has been used for many years in patients with life-threatening hypoxaemia and/or hypercarbia. While early trials demonstrated that it was associated with poor outcomes and extensive haemorrhage, the technique has evolved. It now encompasses new technologies and understanding that the lung protective mechanical...

Debate remains whether the systemic inflammatory response syndrome (SIRS) identifies patients with clinically important inflammation. Defining criteria may be disproportionately sensitive and lack specificity. We investigated the incidence and evolution of SIRS in a homogenous population (following cardiac surgery) over seven days to establish the...

Low voltage DC (LVDC) distribution systems offer improved efficiency and reliability in smart grids. A major challenge facing LVDC systems is DC-AC conversion. A study of an effective low voltage DC-AC converter is therefore presented. Modular Multilevel Converter (MMC) performance (in particular power loss) is compared with a conventional IGBT-bas...

At present High Voltage Direct Current (HVDC) Voltage Source Converters (VSC) are susceptible dc faults leading to extreme currents. The fault current cannot be controlled by the converter switching flows in the anti-parallel diodes. Protection devices are, therefore, required to operate with sufficient speed to avoid device failure. A method is in...

Extracorporeal carbon dioxide removal (ECCO2R) device technologies have enhanced the management of acute respiratory distress syndrome (ARDS) and other lung pathologies necessitating low tidal volume protective ventilation. We report the novel use of the interventional Lung Assist Membrane Ventilator® (iLA, Novalung GmbH) in a multi-trauma patient...

Acute severe clinical deterioration of patients with cystic fibrosis (CF) may mandate endotracheal intubation. The benefits of intubation were evaluated by examining which pre-admission parameters were associated with intensive care unit (ICU) outcome and assessing the potential benefits of intubation for survivors in terms of time from ICU dischar...

Optimal management of the acute respiratory distress syndrome (ARDS) requires prompt recognition, treatment of the underlying cause and the prevention of secondary injury. Ventilator-associated lung injury (VALI) is one of the several iatrogenic factors that can exacerbate lung injury and ARDS. Reduction of VALI by protective low tidal volume venti...

In the previous issue of Critical Care, Vermeulen Windsant and colleagues demonstrate that transfusion of packed red cells is associated with a transient increase in plasma free haemoglobin and scavenging of nitric oxide in vitro. They also demonstrate that older units of blood have more free haemoglobin in their supernatants. Whether the administr...

Purpose: The aim of the present study was to correlate computed tomography appearances with clinical severity and outcome using a total lung disease (TLD) score in patients with acute respiratory distress syndrome (ARDS) related to influenza A H1N1 infection. Materials and methods: Chest computed tomographic scans of 33 patients admitted in the...

Acute lung injury (ALI) and acute respiratory distress syndrome are characterized by protein rich alveolar edema, reduced lung compliance, and acute severe hypoxemia. A degree of pulmonary hypertension (PH) is also characteristic, higher levels of which are associated with increased morbidity and mortality. The increase in right ventricular (RV) af...

In June 2008 the World Health Organization launched its second global patient safety challenge, “Safe surgery saves lives” ( BMJ 2008;337:a2370, doi:10.1136/bmj.a2370). This three part surgical safety checklist aimed to reduce the incidence of wrong site surgeries and increase the surgical team’s preparedness for anaesthetic and surgical complicati...

To investigate differences in cytokine/chemokine release in response to lipoteichoic acid (LTA) or lipopolysaccharide (LPS) and contributing cellular mechanisms, in order to improve understanding of the pathogenesis of sepsis. Levels of cytokines/chemokines were measured in plasma and peritoneal lavage fluid of 10-week-old male mice (C57/B16) follo...

Diabetes mellitus is increasingly prevalent and associated with significant end organ damage that one may presume to impact upon critical illness. However, Siegelaar and colleagues present data that suggest, excepting those patients admitted to a cardiac intensive care unit, the presence of diabetes mellitus is not associated with increased mortali...

Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic. To compare the hospital mortality of patients with H1N1-related ARDS referred, accepted...

Venovenous extracorporeal membrane oxygenation is used increasingly in adults with severe acute reversible respiratory failure. Cannulation is associated with a risk of vascular damage or cardiac perforation. This report describes a modified technique of insertion for dual lumen bicaval cannulae. We have adopted the technique on 25 occasions and ha...

Population, Intervention, Comparison and Outcome (PICO) evidence tables. This file contains structured detail for all studies included in the systematic review. According to GRADE method guidelines, a series of eight study questions was devised to approach the questions posed by the systematic literature review. The PICO table then describes each s...

Pulmonary vascular dysfunction, pulmonary hypertension (PH), and resulting right ventricular (RV) failure occur in many critical illnesses and may be associated with a worse prognosis. PH and RV failure may be difficult to manage: principles include maintenance of appropriate RV preload, augmentation of RV function, and reduction of RV afterload by...

This chapter discusses clinical information systems (CIS). When properly implemented, clinical information systems can improve patient safety and reduce medical error. Decision support is a powerful tool to reduce errors of omission and commission. Clinical information systems can enhance the quality and reduce the burden of clinical audit. Unless...

IntroductionSystemic disordersCardiovascular dysfunctionRenal dysfunctionRespiratory dysfunctionGastrointestinal dysfunctionNeurological dysfunctionSternal wound complicationsConclusion References

The idea of employing cardiopulmonary bypass technology as a means of oxygenating (extracorporeal membrane oxygenation (ECMO)) or removing carbon dioxide (ECCO2R) in patients with acute respiratory failure (ARF) was first assessed in randomised controlled trials in the 1970s and 1980s.1 2 Poor rates of survival and major complications, particularly...

The case histories are presented of three adults who had severe hypercapnic acidosis despite mechanical ventilation with what were considered to be injurious tidal volumes and airway pressures. The use of a percutaneously inserted arteriovenous extracorporeal carbon dioxide removal (AV-ECCO(2)R) device facilitated a dramatic reduction in the amount...

Catheter-related bloodstream infection (CRBSI) accounts for 10% to 20% of hospital-acquired infections in the UK and is associated with both increased ICU stay and mortality. Rates of CRBSI may be modified by clinical care during insertion and utilisation of central venous catheters (CVCs) [1]. As such, the incidence of CRBSI has been proposed as a...

Carbon dioxide is produced as a by-product of the Kreb's cycle that links the metabolism of glucose, lipids and amino acids to oxidative phosphorylation and the aerobic generation of energy within cells. Carbon dioxide is excreted by the lungs. The partial pressure of carbon dioxide (PCO2) in arterial blood (PaCO2) can be viewed in reasonably simpl...

International guidelines concerning the management of patients with sepsis, septic shock and multiple organ failure make no reference to the nature of the infecting organism. Indeed, most clinical signs of sepsis are nonspecific. In contrast, in vitro data suggest that there are mechanistic differences between bacterial, viral and fungal sepsis, an...

Intensive insulin therapy (IIT) has been shown to reduce mortality and morbidity in longer stay, critically ill patients. However, this has been demonstrated in a single site, whereas two multicentric studies have been terminated prematurely mainly due to hypoglycemia. Other difficulties with IIT include efficacy of glycemic control. This report de...

Systemic inflammatory response syndrome (SIRS) is the leading cause of morbidity and mortality in the critically ill. It is associated with a 50% reduction in 5-year life expectancy. SIRS is defined as two of the following criteria: heart rate >90 beats/min, respiratory rate >20 breaths/min or pCO2 38°C, white cell count 12 × 109/l. These criteria...

Severe sepsis dominates the mortality of non-cardiac intensive care units. The ingenious Toll-like receptor (TLR) system can recognise many infectious organisms through relatively few receptors to trigger pro-inflammatory and anti-inflammatory cytokine release. Further complexity arises from positive and negative signalling feedback loops. Severe s...