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Intensive care offers a standard of monitoring, intervention, and organ support that cannot be readily delivered in a general ward. Its expansion in the past few decades, including the creation of emergency and outreach teams, emphasises that intensive care has an increasingly prominent role within the hospital. Although outcomes are clearly improving, intensive care remains a nascent specialty in which we are still learning how to harness a powerful ability to manipulate physiology, biochemistry, and immunology to achieve best outcomes for the patient. The results of many multicentre studies have not lent support to, or have even confounded, expectations, drawing attention to several issues related to patient heterogeneity, trial design, and elucidation of underlying pathophysiological processes. However, these results have generated constructive introspection and reappraisal of treatments and management strategies that have benefited the patient. In addition to the medical, financial, and logistical challenges in the future, exciting opportunities will arise as new developments in diagnostic tests, therapeutic interventions, and technology are used to exploit an increasing awareness of how critical illness should be managed.

Summary Background Over the past 30 years the pulmonary artery catheter (PAC) has become a widely used haemodynamic monitoring device in the management of critically ill patients, though doubts exist about its safety. Our aim was, therefore, to ascertain whether hospital mortality is reduced in critically ill patients when they are managed with a PAC. Methods We did a randomised controlled trial to which we enrolled 1041 patients from 65 UK intensive care units. We assigned individuals to management with (n=519) or without (n=522) a PAC. The timing of insertion and subsequent clinical management were at the discretion of the treating clinician. Intensive care units decided a priori to have the option of using an alternative cardiac output-monitoring device in control patients. Findings 1014 patients were eligible for analysis. We noted no difference in hospital mortality between patients managed with or without a PAC (68% [346 of 506] vs 66% [333 of 507], p=0·39; adjusted hazard ratio 1·09, 95% CI 0·94–1·27). We noted complications associated with insertion of a PAC in 46 of 486 individuals in whom the device was placed, none of which was fatal. Interpretation Our findings indicate no clear evidence of benefit or harm by managing critically ill patients with a PAC. Efficacy studies are needed to ascertain whether management protocols involving PAC use can result in improved outcomes in specific groups if these devices are not to become a redundant technology.

Summary Background Hospital-acquired infection due to meticillin-resistant Staphylococcus aureus (MRSA) is common within intensive-care units. Single room or cohort isolation of infected or colonised patients is used to reduce spread, but its benefit over and above other contact precautions is not known. We aimed to assess the effectiveness of moving versus not moving infected or colonised patients in intensive-care units to prevent transmission of MRSA. Methods We undertook a prospective 1-year study in the intensive-care units of two teaching hospitals. Admission and weekly screens were used to ascertain the incidence of MRSA colonisation. In the middle 6 months, MRSA positive patients were not moved to a single room or cohort nursed unless they were carrying other multiresistant or notifiable pathogens. Standard precautions were practised throughout. Hand hygiene was encouraged and compliance audited. Findings Patients' characteristics and MRSA acquisition rates were similar in the periods when patients were moved and not moved. The crude (unadjusted) Cox proportional-hazards model showed no evidence of increased transmission during the non-move phase (0·73 [95% CI 0·49–1·10], p=0·94 one-sided). There were no changes in transmission of any particular strain of MRSA nor in handwashing frequency between management phases. Interpretation Moving MRSA-positive patients into single rooms or cohorted bays does not reduce crossinfection. Because transfer and isolation of critically ill patients in single rooms carries potential risks, our findings suggest that re-evaluation of isolation policies is required in intensive-care units where MRSA is endemic, and that more effective means of preventing spread of MRSA in such settings need to be found. Published online January 7, 2005 http://image.thelancet.com/extras/04art9304web.pdf

Sepsis and other critical illnesses produce a biphasic inflammatory, immune, hormonal, and metabolic response. The acute phase is marked by an abrupt rise in the secretion of so-called stress hormones with an associated increase in mitochondrial and metabolic activity. The combination of severe inflammation and secondary changes in endocrine profile diminish energy production, metabolic rate, and normal cellular processes, leading to multiple organ dysfunction. This perceived failure of organs might instead be a potentially protective mechanism, because reduced cellular metabolism could increase the chances of survival of cells, and thus organs, in the face of an overwhelming insult. We propose that, first, multiple organ failure induced by critical illness is primarily a functional, rather than structural, abnormality. Indeed, it may not be failure as such, but a potentially protective, reactive mechanism. Second, the decline in organ function is triggered by a decrease in mitochondrial activity and oxidative phosphorylation, leading to reduced cellular metabolism. Third, this effect on mitochondria might be the consequence of acute-phase changes in hormones and inflammatory mediators.

Background Annually, more than 11 million patients are admitted to hospital overnight in England, but the UK is ranked 24 of 31 European countries with respect to per head provision of intensive care unit (ICU) beds. This lack of beds places strain on the capacity to admit patients from the ward because of high ICU occupancy. Such delay can cause harm, but the effect of such harm is difficult to measure. Prompt admissions are prompt precisely because these patients are severely unwell. Measured severity is unlikely to completely capture the clinical judgment used to allocate early admission, and therefore risk-adjusted outcomes will be biased against the early admission. We aimed to evaluate the effect of delayed admission to critical care without this treatment selection bias. Methods We did a prospective cohort study of deteriorating ward patients assessed for critical care admission in National Health Service hospitals in the UK. Early admission was defined as within 4 h of assessment. The primary endpoint was 90-day survival. We used critical care occupancy as an instrumental variable, assuming that a full ICU could only affect outcome of a ward patient by deflecting or delaying admission. Findings 12 495 patients from 48 hospitals were available for analysis of whom 3797 (30·4%) died within 90 days. 4494 (36·0%) patients were admitted to critical care of whom 2492 (55·5%) were admitted early. The median time to admission was 2 h (IQR 1–3) with a bedside decision to admit, and 12 h otherwise (5–29). 991 patients (7·9%) were assessed when the critical care unit was fully occupied. Compared with those assessed when more than one bed was available, these patients were admitted less often (odds ratio [OR] 0·37, 95% CI 0·28–0·48), experienced greater delays (median increase 2 h, IQR 1–3), and deteriorated further while waiting (1·4 ICNARC physiology points, 95% CI 0·4–2·5). Early admission reduced mortality (OR 0·49, 95% CI 0·27–0·89). When averaged across the full population, absolute mortality fell by 13·9% (95% CI 25–23·0). Interpretation Our study has shown that the deteriorating ward patient is vulnerable with a high short-term mortality (none of these patients had treatment limitations). Delays to admission were large and common, and arose both from our inability to perfectly triage these patients, and from limits to the capacity of the system. That these delays cause harm is very likely. Funding Wellcome Trust, National Institute for Health Research Service Support Costs, Intensive Care National Audit & Research Centre.

Norepinephrine-resistant hypotension when associated with septic shock has a high rate of mortality, which might possibly be reduced by infusion of low-dose vasopressin. However, rebound hypotension often arises after treatment is stopped, and the drug usually has to be administered for several days. We report use of terlipressin, a long-acting vasopressin analogue, in eight patients with septic shock who did not respond to corticosteroids and methylene blue. A significant rise in blood pressure that lasted for at least 5 h was seen in all patients after a single bolus, allowing reduction or cessation of norepinephrine administration in seven patients. We were able to discharge four patients from intensive care subsequently. Terlipressin seems to be an effective rescue therapy, which is able to restore blood pressure in patients with catecholamine-resistant septic shock, without obvious complication.

Tumour necrosis factor (TNF) concentrations were measured in the bronchopulmonary secretions of 5 patients with the adult respiratory distress syndrome. Each patient underwent fibreoptic bronchoscopy and bronchopulmonary aspiration, and control samples were obtained in an identical manner from 24 patients who underwent bronchoscopy for other reasons (8 had tuberculosis, 6 had sarcoidosis, and 10 had haemoptysis but no abnormal findings). Aspirated fluid was assayed for the presence of TNF by use of an enzyme-linked immunosorbent assay. In the 5 patients with adult respiratory distress syndrome, TNF concentrations exceeded 500 U/ml (12·5 ng/ml), whereas in the control samples no TNF was detected.