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Older people admitted to intensive care are considered to have lower physiological reserves, an increased susceptibility to infection and longer recovery times, resulting in generally poorer outcomes after intensive care treatment. However, biological heterogeneity makes identification of those with the best chances of survival within their group difficult and risks subjecting those at the end of their lives to unsuccessful treatments. There is no fit-for-purpose outcome prediction tool capable of identifying patients most at risk of these poor outcomes at the point of admission to intensive care. This retrospective study sought to identify factors associated with mortality in older patients (≥70 years) admitted to a teaching hospital critical care unit using objective variables readily available at the point of admission. A total of 15 variables were tested for a significant association with mortality. Of these, eight were identified as significant variables (myocardial infarction within 6 months, an abnormal ECG, congestive cardiac failure (NYHA ≥2), chronic pulmonary disease, chronic liver disease, metastatic cancer, a stay in hospital ≥5 days preceding ICU admission, and frailty (Clinical Frailty Score ≥4)). These variables were used from the basis of a novel outcome prediction model. The aim of such a model would be that it could be used at the point of referral to intensive care to inform considerations regarding admission, and to facilitate conversations with the patient and family regarding realistic treatment expectations.

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The Faculty of Intensive Care Medicine distributes an annual survey to its Consultants, allowing the evaluation of workforce profile, working patterns and the opportunity for analysis of key information on issues affecting these. We undertook an exploratory review of the data provided within the 2016 survey, with the aim of identifying themes within respondents stated career intentions and associated factors. Given the modest (36%) response rate, we are unable to draw conclusions with certainty, but there are indications within the data that the UK Intensive Care Medicine consultant body is facing significant stressors whilst at work, due to working patterns and limited resources. The data within the 2016 survey provide a base from which to develop future Faculty of Intensive Care Medicine workforce surveys that will extract data about the positive aspects of a career in intensive care medicine. The survey data provide a signal that there may be significant potentially modifiable stressors for intensive care doctors, and as such affords support for initiatives to improve job planning and sharing of implemented solutions, as well as a need to focus on workforce wellbeing as an important and necessary contributor to patient safety within intensive care medicine.

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Adverse events and complications, even if minor, can result in considerable negative effects on patients, including loss of life. They can also have an impact on the healthcare workers involved. Offering an apology to a patient who has suffered a complication is necessary, and is not an admission of fault. In England and Wales, there are also statutory obligations of candour in cases of more severe notifiable events. Local and national systems exist for incident reporting, with a strong emphasis on learning from events and sharing of best practice. Complaints may arise from poor management of a patient's complications, and in situations where there is a clear breach of a professional duty that has resulted in patient harm, negligence may be deemed to have occurred. National Health Service Resolution focuses on learning from events to help reduce the growth in litigation and emphasises that discussions should be timely, include appropriate explanation and information, and provide ongoing support and, if necessary, continuity of care.

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Approximately 12% of apparently previously cognitively well patients undergoing anaesthesia and noncardiac surgery will develop symptoms of cognitive dysfunction after their procedure. Recent articles in this Journal have highlighted the difficulties of confirming any clear links between anaesthesia and cognitive dysfunction, in part because of the lack of consistency regarding definition and diagnosis. Postoperative cognitive dysfunction (POCD) is usually self-limiting and rarely persists in the longer term, although plausible biological mechanisms for an impact on brain protein deposition do exist. Clinical research studies are frequently confounded by a lack of agreed definitions and consistency of testing. Preoperative assessment of neurocognitive function and risk factor identification is imperative in order to ascertain the true extent of POCD and any causative link to anaesthesia and surgery. At present a multidisciplinary care bundle approach to risk factor stratification and reduction is the most attractive management plan based on evidence of slight benefit from individual interventions. As yet no individual anaesthetic technique, drug or mode of monitoring has been proved to reduce the incidence of POCD. Providing patients with appropriate and accurate information can be difficult because of conflicting evidence. The Royal College of Anaesthetists' patient liaison group has produced a useful patient information leaflet that is designed to provide guidance in discussions of individual risks whilst considerable uncertainties remain.

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Non-invasive ventilation (NIV) is a supportive therapy that improves mortality in acute respiratory failure (RF). It may also be used in patients recently extubated in intensive care units (ICUs), after operation, and to aid weaning from mechanical ventilation (MV) by reducing the morbidity and mortality associated with further MV. A meta-analysis of the available evidence was performed on the use of NIV in three areas: weaning, reduction in reintubation rates post-extubation on ICU, and reduction in RF after major surgery. Sixteen relevant randomized controlled trials were identified by three reviewers after a detailed search of identified medical databases. A meta-analysis of summary statistics relating to predetermined endpoints (ICU and hospital length of stay, ICU and hospital mortality, reintubation, pneumonia) was performed. NIV reduced the ICU length of stay when used for weaning (5.12 days) and post-surgery (0.44 days). NIV reduced reintubation rates post-surgery [odds ratio (OR) 0.24, 95% confidence interval (CI) 0.12-0.50] and the incidence of pneumonia in weaning (OR 0.12, 95% CI 0.05-0.31) and post-surgery (OR 0.27, 95% CI 0.09-0.77). There was insufficient evidence to suggest that NIV improves ICU survival, but an increased hospital survival in post-surgery (OR 4.54, [corrected] 95% CI 1.35-15.31) and a reduction after weaning (OR 0.55, 95% CI 0.31-0.98) [corrected] was seen. A meta analysis of NIV use in selected subgroups of recently extubated patients suggests that the judicious NIV use may reduce ICU and hospital length of stay, pneumonia, and reintubation rates and hospital survival.

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Teaching medical ethics and law has become much more prominent in medical student education, largely as a result of a 1998 consensus statement on such teaching. Ethics is commonly taught at undergraduate level using lectures and small group tutorials, but there is no recognised method for transferring this theoretical knowledge into practice and ward-based learning. This reflective article by a Sheffield university undergraduate medical student describes the value of using a student-selected component to study practical clinical ethics and the use of a clinical ethics checklist. The ethical checklist was proposed by Sokol as a tool for use by medical staff during the ward round to prompt the consideration of important ethical principles in relation to care. This paper describes additional uses for the checklist as a tool for teaching and learning about the practical application of ethical principles and for observing professional behaviours within a critical care and acute care environment. Evidence suggests that putting ethical behaviour into practice offers a far greater challenge to a newly qualified doctor than has been appreciated, and that more needs to be done at an undergraduate level to help combat this. This paper argues from a personal standpoint of an individual student experience that this can best be done in a clinical medical setting.

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In December 1996, the Association of Anaesthetists of Great Britain and Ireland produced a series of recommendations outlining the safe conduct of interhospital transfers for patients with acute head injuries. We assessed the current ability of UK hospitals to implement these recommendations and opinions on the formation of transfer teams, using a postal questionnaire. This was sent to all Royal College of Anaesthetists tutors, 268 of whom replied (94% response rate). Of the hospitals surveyed, 208 received adult head-injury patients but did not have on-site neurosurgical facilities. In 171 (86.8%) of these hospitals, senior house officers could be expected to accompany the patient during subsequent transfer. The majority of hospitals (192, 92.3%) were able to monitor ECG, pulse oximetry and blood pressure during the journey, but only 97 (46.6%) had facilities to monitor end tidal carbon dioxide levels. As a result of the anaesthetist's involvement in the transfer, emergency operating could be delayed in 169 (81.3%) hospitals. One hundred and fifty-eight (76%) respondents thought that the formation of transfer teams to transport critically ill patients would have some merit. Hospitals are responding to the published guidelines, but improvements are still needed in levels of equipment and insurance provision, along with the identification of a designated consultant at each hospital with responsibility for transfers.

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Eight nurses with no previous experience of advanced airway management were randomly assigned to be taught tracheal intubation either by direct laryngoscopy or via a laryngeal mask. Once competent in the technique using a manikin, they attempted a maximum of ten intubations on anaesthetised patients. They were then taught the alternative technique and the assessment repeated. Median times for practice were the same for both techniques. Intubation in under 30 s was successful via the laryngeal mask in 60% of patients (42/70) compared to 39% (27/70) when using a laryngoscope (P = 0.11). It appears that non-medical personnel can be successfully taught to intubate the trachea using the laryngeal mask as a conduit, for those circumstances where a cuffed tracheal tube is considered essential during resuscitation.

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The aim of this study was to assess the respiratory changes following reduction mammaplasty in women presenting for elective surgery; In addition, to assess whether these changes might be related to any symptomatic improvement. This was a prospective study examining women attending for breast reduction surgery over a 3-month period. Preoperative pulmonary function studies (PFTs) and a symptom questionnaire were completed before operation. These were repeated 6-8 weeks after surgery. Pulmonary function testing was carried out in all cases by the same operator. The study was carried out within a sub regional centre for plastic and reconstructive surgery. Local Ethics committee approval was obtained. Nineteen healthy women mean age 34.9 years and with a mean Body Mass Index of 27.62 were recruited. The mean weight of excised breast tissue was 1546 g. All preoperative pulmonary function tests were within normal limits. Six of the women smoked, none changed their smoking habits over the course of this study. Changes in pulmonary function studies were analysed using the paired t-test. A 'P' value of < 0.05 was considered to be significant. Seventeen women had a post operative improvement in PFTs. Statistically significant improvements were obtained for changes in peak expiratory flow rate (PEFR, P = 0.005) and peak inspiratory flow rate (PIFR, P < 0.0001). The 'P' values for changes in FEV1 (forced expired volume in 1 second) and FEV1/FVC (forced vital capacity) did not reach significance, whilst the 'P' value for the change in FVC was statistically significant (P = 0.01), although the actual mean change was small (0.07 litres). The study sample was too small to relate these changes to mass of excised tissue or BMI. All women taking part claimed an increased confidence and a cessation in analgesic use. Other reported benefits included an improved exercise tolerance (12/19), reduced sleep disturbance (4/19) and reduced breathing difficulties (1/19).

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