We return to our 48-year-old patient: jaundiced, hypotensive, drowsy, and bleeding. In decompensated cirrhosis, every treatment targets a disrupted system — splanchnic vasodilation, portal hypertension, toxin accumulation, and renal hypoperfusion.

Although these patients look fluid overloaded, they are effectively hypovolaemic. Start with small aliquots of balanced crystalloid, avoiding 0.9% saline. In hepatorenal syndrome or tense ascites, 20% albumin is key — not just for volume expansion, but for circulatory and anti-inflammatory support.

Once volume is optimised, flow must be redirected. Terlipressin reverses splanchnic vasodilation, reduces portal pressure, and improves renal perfusion. If contraindicated, noradrenaline targeting a MAP ≥65 mmHg is an effective alternative.

Variceal bleeding reflects portal hypertension, not missing clotting factors. Use restrictive transfusion, correct platelets and fibrinogen selectively, start antibiotics early, and proceed to endoscopic banding once haemodynamically stable. Avoid blanket correction of INR — treat bleeding, not numbers.

Hepatic encephalopathy management focuses on reversing precipitants and reducing ammonia with lactulose and rifaximin, while protecting the airway in advanced grades. Infection screening is essential — SBP and sepsis worsen vasodilation and renal failure, with albumin improving outcomes.

Renal dysfunction is functional, not structural. Albumin plus vasoconstrictors can restore perfusion. Nutrition is critical: early enteral feeding with adequate protein supports recovery and ammonia clearance.

Bottom line: cirrhosis care works when physiology drives every decision.

In this episode, I walk through the real-world critical care management of acute decompensated alcohol-related liver disease, using a high-risk ICU case to anchor the discussion. The focus is on understanding the underlying physiology—portal hypertension, rebalanced haemostasis, hepatic encephalopathy, infection, and hepatorenal syndrome—and translating that physiology into clear first-hour priorities at the bedside.

Listeners are guided through airway and circulatory decision-making, rational use of albumin, vasopressors, antibiotics, lactulose and rifaximin, and careful blood product transfusion, while avoiding common pitfalls such as reflexive FFP or over-resuscitation.

The episode emphasises early recognition of red flags, the central role of infection as a precipitant, and the interconnected nature of multi-organ failure in acute-on-chronic liver disease, all framed within pragmatic UK ICU practice.

This episode offers a structured, bedside-focused exploration of Non-Invasive Ventilation (NIV) for acute hypercapnic respiratory failure in COPD, aligned with NICE NG115 and BTS/ICS 2016 guidance. Aimed at early-career critical care nurses, it breaks the topic down into physiology, practical setup, monitoring, and escalation.

Key Topics Covered

• Mechanisms behind acute-on-chronic hypercapnic respiratory failure in COPD.

• How NIV improves ventilation, reduces CO₂, and decreases work of breathing.

• Evidence-based indications for NIV initiation.

• Practical bedside steps for the first hour of therapy.

• How to titrate settings, troubleshoot problems, and recognise failure.

• Common complications and when to escalate to invasive ventilation.

Case-Based Learning
The episode follows Mr. Harris, a 68-year-old man with severe COPD presenting with type 2 respiratory failure. His clinical deterioration, ABG results (pH 7.25, pCO₂ 9.8 kPa), and work of breathing set the scene for understanding when and why NIV is beneficial.

Physiology Essentials
Listeners are guided through the impact of airway obstruction, air trapping, hyperinflation, respiratory muscle fatigue, and CO₂ narcosis. NIV’s core actions—improving tidal volume with IPAP and splinting airways with EPAP—are linked directly to these mechanisms.

Practical Bedside Framework

• Start with IPAP 12 cmH₂O / EPAP 4 cmH₂O and FiO₂ around 28%, aiming for SpO₂ 88–92%.

• Reassure the patient, optimise positioning, secure a comfortable mask seal, and monitor synchrony.

• Repeat ABG at 1 hour; look for rising pH and falling CO₂.

• Adjust pressures in small increments if needed while monitoring for leaks, agitation, hypotension, or gastric distension.

Monitoring and Escalation
Success indicators include reduced respiratory rate, improved alertness, and trending normalisation of pH. Red flags include worsening acidosis, declining consciousness, mask intolerance, or inability to maintain the airway—prompting urgent senior review.

Common Complications
Facial pressure sores, gastric distension, aspiration risk, anxiety, and haemodynamic compromise are highlighted with practical prevention strategies.

Five Golden Rules

1. Recognise early and initiate NIV promptly.

2. Start simple with standard pressures and controlled oxygen.

3. Reassess rapidly with a 1-hour ABG.

4. Escalate quickly if failure criteria develop.

5. Protect the patient with meticulous care and communication.

Outcome
After an hour of NIV, Mr. Harris’ pH rises to 7.32 and pCO₂ falls to 8.2 kPa, with clear clinical improvement—illustrating the value of timely, well-managed NIV in COPD.

Closing
The episode reinforces the importance of physiological understanding in delivering confident, effective NIV care at the bedside.

HHS (Hyperosmolar Hyperglycaemic State) is the quiet counterpart to DKA. It develops slowly in older type 2 diabetics with residual insulin, leading to extreme hyperglycaemia and dehydration without ketosis. In this 2-hour deep dive, Jonathan explains why HHS kills through water loss and hyperviscosity rather than acid, and how to manage it safely.

Key Learning Points:

·         Pathophysiology: Relative insulin deficiency → no ketones, but relentless osmotic diuresis → hyperosmolarity > 320 mOsm/kg.

·         Recognition: Elderly, confused, profoundly dehydrated, glucose often > 30 mmol/L, Na⁺ high, pH > 7.3.

·         Fluids first: Replace ~½ deficit in 12 h with 0.9 % saline; adjust for heart/kidney function.

·         Insulin later: 0.05 u/kg/hr once osmolality is falling; aim glucose fall 3–6 mmol/L/hr.

·         Add dextrose when glucose ≈ 14 mmol/L to avoid cerebral oedema.

·         Potassium vigilance: Replace according to level; withhold insulin if < 3.5 mmol/L.

·         Thromboprophylaxis essential.

·         Monitoring: Hourly glucose & neuro obs, 2–4-hourly U&Es/osmolality, strict fluid balance.

·         Complications: Cerebral oedema, VTE, renal injury, electrolyte shifts, rhabdomyolysis.

·         Take-home: In HHS, correct the water slowly, the sugar gently, and never forget the brain.

Diabetic ketoacidosis (DKA) is not just “high blood sugar” — it’s a hormonal storm caused by absolute insulin deficiency and a surge of counter-regulatory hormones. The result is a triad of hyperglycaemia, dehydration, and metabolic acidosis.

We follow Sophie, a 23-year-old with type 1 diabetes who arrives with vomiting, Kussmaul breathing, glucose 28 mmol/L, ketones 5.6 mmol/L, and pH 7.08.

🔍 What’s Going Wrong?

• No insulin → cells can’t use glucose → liver produces more.

• Glucose spills into urine → osmotic diuresis → 6–8L fluid + electrolyte loss.

• Fat breakdown produces ketones → metabolic acidosis.

• Potassium appears normal or high, but total body stores are low.

💉 Treatment Logic (Always in This Order):

1. Fluids first – 1L 0.9% NaCl over 30 mins (slower if frail/cardiac issues). Restores perfusion, lowers stress hormones.

2. Potassium next – replace before insulin if K⁺ <3.5 mmol/L; add to fluids if 3.5–5.5.

3. Insulin third – fixed-rate 0.1 units/kg/h to stop ketone production, not to chase glucose.

4. Add 10% dextrose when glucose falls to ~14 mmol/L to safely continue insulin.

5. Treat the trigger – infection, missed insulin, MI, etc.

✅ Key Message

DKA isn’t chaotic when understood physiologically. Fluids, potassium, insulin — in that order. You’re not treating the number; you’re fixing the metabolic storm.

Summary:
In this episode, we spotlight a stealthy ICU disruptor — hypophosphataemia. Based on a 2024 narrative review in the Journal of Clinical Medicine, we explore why phosphate matters, how it goes missing in critically ill patients, and why you should care even when it’s just “a little low.”

What’s Covered:

• The vital role of phosphate in energy, oxygen delivery, and muscle function

• Why hypophosphataemia affects 20–80% of ICU patients

• Clinical consequences, from muscle weakness to respiratory failure, arrhythmias, and delirium

• Common causes: refeeding, DKA, diuretics, malnutrition, and sepsis

• Replacement options — and why there's no universal guideline

• When to go IV, when oral might suffice, and what risks to watch for

Key Takeaways:

• Don’t overlook mild phosphate drops — they’re not always benign

• Severe hypophosphataemia (<0.4 mmol/L) can be life-threatening

• Consider protocols for screening and replacement in high-risk ICU patients

• More research is needed, but clinical awareness matters now

Final Thought:
Phosphate might be the quiet ninja of the ICU — when it vanishes, chaos isn’t far behind. Check your labs, trust your gut, and give phosphate the respect it deserves.

• What is DKA? – The triad of hyperglycaemia, ketonaemia, and metabolic acidosis (JBDS 2023 definitions).

• Pathophysiology explained – Insulin deficiency, ketone production, and why potassium is so tricky.

• Clinical features – Polyuria, dehydration, Kussmaul breathing, acetone breath, and red flags for deterioration.

• Investigations – Capillary ketones, blood gases, electrolytes, ECG, and screening for precipitants.

• Management (UK guidelines) – Fluids first, fixed-rate insulin infusion, careful potassium replacement, and always treat the trigger.

• Pitfalls – Starting insulin before fluids, forgetting potassium, dropping glucose too quickly, or missing the underlying cause.

• Case vignette – A young woman with type 1 diabetes presenting in DKA, walking through priorities and pitfalls in real time.

🔑 Key takeaways:

• DKA = fluids first, insulin second, potassium throughout.

• Monitor closely and stick to the JBDS 2023 UK protocol.

• Always identify and treat the precipitating cause.

Mobilisation in the ICU raises two big questions: is it safe, and will staff embrace it?

In this discussion, Jonathan explores both sides of the story:

• Safety first:

  • Large prevalence studies show mobilisation is happening, though often inconsistently.

  • A systematic review of 1,800+ sessions found serious adverse events in only 0.6% — most minor and short-lived.

  • Even patients on CRRT can safely mobilise with planning, adequate staff, and the right equipment.

  • Consensus guidelines outline clear safety screens, covering oxygen, ventilator settings, vasopressors, and line security.

• Culture and barriers:

  • Staff concerns include safety fears, deep sedation, lack of hands, limited kit, and “whose job is this anyway?”

  • Interviews reveal gaps in knowledge and confidence, differing beliefs about risks and benefits, and role confusion between professions.

  • Success breeds success: once teams see mobilisation working, attitudes shift.

  • Daily goals, interdisciplinary huddles, and local champions help make mobilisation the default, not the exception.

Takeaway: Mobilisation in ICU is both safe and achievable — but safety checks alone aren’t enough. Embedding it into everyday culture is the real key to making it routine.

Summary
For much of critical care history, immobility was the norm: patients were sedated, kept still, and “protected.” But decades of research have revealed the hidden costs — profound muscle wasting, delirium, and long-term disability.

Jonathan explores how our understanding of mobilisation in ICU has evolved — from the recognition of harm caused by bedrest, to the first landmark studies proving that early movement is both feasible and beneficial.

From Bedrest to Better: Why Mobilise in ICU?

• ICU-acquired weakness: Patients can lose 15–20% of muscle mass within the first week of critical illness.

• Long-term outcomes: ARDS survivors tracked for five years showed persistent disability and reduced independence.

• Sedation & delirium: Deep sedation increases delirium risk; mobilisation reduces both incidence and duration.

• Physiological rationale: Even minimal movement supports cardiovascular tone, respiratory function, circulation, and cognition.

• Core message: Bedrest is not neutral — it is actively harmful. Mobilisation offers protection for both brain and body.

Proof in Practice: The First Mobilisation Trials

• Feasibility (Morris et al., 2008): Protocol-led mobilisation cut time to first mobilisation (5 vs 11 days), with no increase in adverse events.

• Landmark RCT (Schweickert et al., 2009):

  • Early PT/OT + daily sedation interruption vs SAT alone.

  • 59% vs 35% regained independence at discharge.

  • Patients had less delirium and spent fewer days ventilated.

• Implementation (Needham et al.): Demonstrated how embedding mobilisation into daily ICU practice improves outcomes and serves as a model for quality improvement.

• Core message: Early mobilisation is not only possible — it improves patient-centred outcomes safely.

Key Takeaways 

• Bedrest and heavy sedation accelerate weakness, delirium, and disability.

• Mobilisation is both biologically plausible and clinically effective.

• Early trials proved feasibility, safety, and functional benefits.

• Success requires:

  • Lighter sedation targets and daily SATs.

  • Interdisciplinary teamwork (nursing, PT/OT, medical).

  • Structured protocols and safety screens.

Overall message: Mobilisation should no longer be an afterthought in ICU. It is a therapeutic intervention — one that supports recovery, preserves dignity, and helps patients walk out of intensive care with more than just survival.

Sedation practices in the ICU have evolved dramatically over the past decade — but are we truly following the evidence?

In this episode of The Critical Care Practitioner Podcast, Jonathan takes you through the key milestones in sedation guidance, the persistent gap between recommendations and real-world practice, and the emerging shift toward human-centered, wakeful care.

What You’ll Learn in This Episode:

• PAD Guidelines (2013) & beyond: How Barr et al. and later ATS/CHEST summaries shaped modern sedation practice.

• Where we fall short: Why deep sedation is still common and the barriers to lighter, protocolised care.

• Human-centered sedation: The move from “snowed and stable” to “awake and engaged.”

• Future directions: Personalised sedation, integrated bundles, non-pharmacologic strategies, and technology-driven monitoring.

• Practical takeaways: Simple steps you can apply on your next shift — from setting clear sedation targets to working as a team toward wakefulness and recovery.

Key Takeaway

Sedation is not passive. It’s an active, daily decision that influences survival, recovery, and dignity. The future of ICU care is one where wakefulness is a therapeutic goal — not a risk

Overview
In this episode we explore the three main sedatives used in critical care and how to choose the right agent for the right patient.

Highlights

• Benzodiazepines: once the workhorse of ICU sedation, but now linked to more delirium and longer ventilation. Still useful in alcohol withdrawal and seizures.

• Propofol: rapid on/off, easy to titrate, helpful for daily sedation holds and neuro assessments. Watch for hypotension, lipid issues, and the rare risk of infusion syndrome.

• Dexmedetomidine: provides light, cooperative sedation with minimal respiratory depression and less delirium, though bradycardia and hypotension are common drawbacks.

Takeaway
No single “best” sedative exists. Match the drug to the patient’s needs and clinical goals — and remember, keeping sedation light is often more important than which agent you use.

We’ve explored the history of sedation in ICU, the impact of daily awakening trials, and the risks of deep sedation. In this episode, we focus on how to embed that evidence into practice — through the use of structured sedation protocols.

Protocols don’t just provide guidance; they transform everyday ICU culture, reduce variation in care, and improve outcomes. But implementing them isn’t always easy. This episode explores the why, what, and how of sedation protocols — and the cultural shift they demand.

What You’ll Learn in This Episode

• 🏥 Why protocols were needed: how variation in sedation practices led to prolonged ICU stays and unpredictable patient journeys.

• 🧪 What makes up a sedation protocol: RASS targets, daily sedation holds, nurse-led titration, and structured decision-making.

• 📊 Evidence that protocols work: from Brook’s 2000 trial to the PAD guidelines and beyond.

• 🔄 Barriers to implementation: fear of agitation, staff training gaps, inconsistent documentation, and cultural resistance.

• 🛠️ Real-world examples: quality improvement projects that boosted compliance and shortened ventilation times.

• 🎯 Protocols as safety nets: creating safe, evidence-informed defaults while leaving room for clinical judgment.

Key References

• Brook AD, et al. JAMA. 2000.

• Martin J, et al. Intensive Care Med. 2001.

• Mehta S, et al. Lancet. 2008.

• Barr J, et al. Crit Care Med. 2013 (PAD Guidelines).

• Schmidt GA, et al. ATS/Chest Guidelines. 2016.

• Mehta S, et al. Crit Care Med. 2012.

• Ferraioli S, et al. BMJ Open Qual. 2019.

Takeaway Message

Sedation protocols are not about rigid rules — they’re about shared standards, safety, and empowerment. They help us move from practice variation to consistent, evidence-based care that improves both efficiency and patient outcomes.

If your ICU already uses a protocol, engage with it fully. If not, perhaps it’s time to start the conversation

Episode 3 – Sedation Depth: How Deep Is Too Deep?

In this third part of our sedation series, we explore one of the biggest game-changers in ICU practice: sedation depth.

For years, the approach was “sedate and stabilise” — often to deep levels. But mounting evidence tells a different story: early deep sedation, especially in the first 48 hours, worsens outcomes.

📉 The risks of deep sedation

• Higher hospital and 180-day mortality (SPICE study, Shehabi et al., 2013)

• Longer time to extubation and ICU stay

• Increased long-term disability

🧠 Sedation and delirium

• Strong links between deep sedation and ICU delirium (Ely et al., 2005; Tanaka et al., 2014)

• Delirium predicts worse survival and cognitive outcomes

🏥 Impact on ventilation and recovery

• More time ventilated

• Higher risk of infections

• Longer ICU and hospital stays

🛠️ Strategies for safer practice

• Set clear sedation targets (RASS –1 to 0)

• Protocolised, nurse-driven sedation adjustment

• Start light and reassess frequently

• Deep sedation only when clearly indicated (e.g., severe ARDS, TBI, refractory agitation)

Takeaway:
Early deep sedation is a modifiable risk factor. The mantra is simple: “light unless otherwise indicated.” Less really is more — and safer.

In this episode, I explore the origins and evolution of the daily sedation hold — also known as the spontaneous awakening trial (SAT) — one of the most influential shifts in ICU sedation practice.

I unpack the key trials that demonstrated SATs could safely reduce ventilation time and ICU stay, and examines how these findings became standard care. But it's not all straightforward — SATs come with implementation challenges, especially when protocols are already in place.

Key topics:

• The evidence behind daily sedation interruption

• How SATs reduce ventilation and improve survival

• Why some ICUs still hesitate to adopt them

• What makes implementation successful in real life

• How SATs have reframed sedation from passive to purposeful

Kress et al. (2000). Daily interruption of sedative infusions in critically ill patients.

Girard et al. (2008). Awakening and breathing controlled trial.

Mehta et al. (2012). Daily sedation interruption in protocolized sedation: RCT.

Ferraioli et al. (2019). Quality improvement project on SAT compliance.

Schmidt et al. (2016). ATS/Chest guidelines on sedation minimization

In this episode, I explore how sedation practices in critical care have evolved over time — from the routine use of deep, continuous sedation to the early evidence that challenged it. You'll hear about pivotal studies that revealed the risks of over-sedation, the emergence of structured sedation protocols, and the beginnings of a culture shift toward lighter, more patient-centered care.

Key topics:

• The rise of continuous sedation in early ICU care

• Landmark studies questioning deep sedation

• Early implementation of sedation protocols

• How sedation culture began to change

Kress et al. (1998). The use of continuous i.v. sedation is associated with prolongation of mechanical ventilation.

Brook et al. (2000). A prospective evaluation of empiric versus protocol-based sedation and analgesia.

Novaes et al. (1999). Stressors in ICU: perception of the patient, relatives, and health care team.

Martin et al. (2001). Sedative and analgesic practice in the intensive care unit: the results of a European survey

This is a conversation I had with Francesca Trotta, a nurse from Rome who is at the last stages in her PhD. This was at the BACCN conference in Aberdeen in 2024.

This is a chat I had with David Wightwick who is the CEO of UK Med a humanitarian medical aid charity. This happened at the BACCN 2024 conference in Aberdeen.

This is a conversation I had with professor Tim Buchman who is Professor of Surgery and founding director at the Emory Centre for Critical Care in the US. 

We discuss the advent of Advanced Practice in the US and how it will inform the same developments in the UK

AI is here! How will it effect us and how can we use it, or not use it to help with our work? Aarti gives some easy to understand explanations of the key concepts.

This is a chat with Rowan Grieves who works in Belfast about her journey to become an ACCP and the hurdles she had to overcome when starting this new role.

This was originally a Facebook livestream with an ex patient- Carol Billian, Christine representing ICU Steps, a group helping support ICU survivors and Peter Nydahl from Germany who also aims to support the same group.

This is a chat I had with Dr Daniel Watkin about his QI project to assess compliance with the guidelines and how they went about improving it.

You can find the paper here- 'Beyond Audit: Embracing QI methodology to drive improvements in lung-protective ventilation'

This is a chat with Tamas Szakmany about the paper 'Impact of early tracheostomy versus late or no tracheostomy in nonneurologically injured adult patients: a systematic review and meta analysis' and his editorial 'When more could mean less intervention: the tale of tracheostomy timing in critical illness'

This is a chat with professor John Laffey about the WEAN_SAFE study. 

Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

A discussion with Michelle about the recent paper she played a part in discussing the conversation s we have, or don't about Do No Resuscitate orders.

The experiences of adult patients, families, and healthcare professionals of CPR decision-making conversations in the United Kingdom: A qualitative systematic review.

Brigitta and colleagues have just published 'The rate and assessment of muscle wasting during critical illness: a systematic review and meta-analysis.'

Some important and interesting discussion points.

Great discussion with Dr Emma Ridley a dietitian from Australia about how they planned to look after the nutritional requirements of COVID patients. A lot of pointers about how we care for their needs when they haven't got COVID too. 

https://www.nejm.org/doi/full/10.1056/nejmoa1214103

I am going to continue this series of podcasts by looking at the other evidence.

Let's get a better understanding of what that waveform is telling us!

Let’s talk about the equipment we use when we decide to intubate our patients. Some understanding of their features is helpful.

A new series which I am hoping to provide weekly taken from the livestreams I am running across social media- this weeks topic- why do we intubate our patients?

A new series which I am hoping to provide weekly taken from the livestreams I am running across social media- this weeks topic- the basic ventilator screen. Lets go through some of those buttons.

A new series which I am hoping to provide weekly taken from the livestreams I am running across social media- this weeks topic- Peak and Plateau Pressures. What are they and why does it matter?

Catherine presented recently at the BACCN conference discussing some of the issues our patients have when they leave the intensive care and how we might help.

Tell me who you are and where you work- Paediatric Nurse Consultant
What is your background- Paediatirc nurse
Why did you decide to go into advanced practice- Career options limited, spotted job opportunity
What was your biggest struggle during your training- academia and developing clinical knowledge
What was the part you found less difficult than you thought you would- Adapting into the clinical role
Give one question you would ask at interview- What is their enthusiasm for advanced practice.
Name one resource you have found most useful- Don't forget the bubbles website
Who do you admire most professionally.- Katie Barnes- developed advanced practice framework

Tell me who you are and where you work- Medicine/renal
What is your background- Paramedic
Why did you decide to go into advanced practice- Longevity for career. Opportunities limited in para medicine
What was your biggest struggle during your training- Belief and role transition. Dis jointed learning

What was the part you found less difficult than you thought you would- clinical examination and procedures
Give one question you would ask at interview- would ask the interviewers how they were going support the 4 pillars
Name one resource you have found most useful- social media/podcasts/journal
Who do you admire most professionally.- Jerry Mortimer, now a lecturer, but always very inspirational

What Matters to Patients and Their Families During and After Critical Illness: A Qualitative Study

'Critically ill patients' experience of agitation: A qualitative meta-synthesis' Nursing in Critical Care 2021

A revisit of one of my most popular episodes- mechanical ventilation with respiratory therapist Ollie Poole.

Sean and I chat about his experiences as an ACCP and he tells us of his struggles and those things that were not as difficult as he expected.

This is a discussion with Shannon Fernando on his recent paper in the BMJ about some of the mental health issues survivors of Critical care may have. 

Suicide and self harm in adult survivors of critical Illness: a population based cohort study.

Robin and Lee both joined me to talk about their journey on the advanced practice route and to share their advice.

My good friend and colleague Rob Fenwick (@robfenwick) and I chatted about the article he was involved in "Productivity of Advanced Clinical Practitioners in Emergency Medicine: A 1-year dual-centre retrospective analysis" 

Rob is an Advanced Clinical Practitioner in the West Midlands in the Emergency Medicine department. He is also one of the members of the fabulous podcast The Resus Room (@TheResusRoom) which I highly recommend!

This is a discussion with Dr Mark Ramzy, an EM and Critical Care Doctor in Pittsburgh. 

His infographic on the various options open to us in the treatment of the patient with ARDS caught my eye on twitter so I managed to chat to him about it.

I am joined by Yogesh Apte, a doctor based in Australia, who recently went through a plan, do, study, act cycle with his team in critical care to ensure they prone well and safely. The article this is based on is below.

Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019

This is a discussion I had with several others on Facebook Live about setting up and the use of ICU Follow Up Clinics. Some of those on the panel were new to it and some had existing clinics so shared valuable information.

Kimberley Kirkbright presented her poster at the recent virtual BACCN 2020 conference. She is a keen user of in situ simulation in her department and has set up a program to make it effective. We can all learn something from this.

Here my friend Jon White (@TechNurseJon) chats with Suzanne Lee (@TheHappyLass) founder of Pivotal Reality, VR AR Consultancy for apps with purpose and VR for Dementia specialist, about how we could start thinking about VR in Critical Care.

David Aaronovitch (@DAaronovitch) is a journalist, author and regular reporter with The Times. He was also an intensive care patient and suffered with a frightening delirium. We discuss this along with Dr Julie Highfield (@DrJulie_H) to see how we as intensive care practitioners can help.

A conversation between Zudin Puthucheary, Senior lecturer and consultant in intensive care medicine, Dr Caroline Sampson, consultant in Anaesthesia and Critical Care, deputy director for Adult ECMO, Glenfield Hospital and Dr Dan Harvey, Intensive care consultant, Nottingham University Hospitals and a member of the legal and ethical advisory group of the Intensive Care Society who is the author of "CRITCON-Pandemic Levels: a stepwise ethical approach to clinician responsibility." 

A conversation between Zudin Puthucheary, Senior lecturer and consultant in intensive care medicine, Julia Hadley, also a consultant in critical care and lead for the Royal London guidelines for tracheostomy in the COVID patient and Dr Brendan McGrath who is the national clinical lead for the same. 

Ollie (@respreview) is now a Doctor, having been a respiratory therapist. He has made a video over on YouTube breaking down the SCCM guidelines. He very kindly agreed that this could also be made into a podcast for those that would rather just listen. Thanks Ollie.

I was very lucky to be contacted by Dr Zudin Puthucheary, Senior Lecturer and Consultant in Intensive Care Medicine, who asked me to record this conversation between himself and Dr Jim Buckley, Consultant in Intensive Care medicine, and Dr Brijesh Patel, Clinical Senior Lecturer and Consultant in Cardiothoracic Intensive Care. 

This discussion focuses on what is potentially the early stages of the crisis the NHS is about to face. Lots of great insights to take away!

This a an audio version of the espresso teaching on the BACCN website which you can find here- https://www.baccn.org/about/covid-19-nurse-educational-resource-centre/espresso-virtual-education/

I got together with my good friend Dr Segun Olusanya (@iceman_ex) to talk about the use of paralysis in ARDS and the Rose Trial. Segun picked this apart for us in his post at The Bottom Line  and he and I chat about this and its implications. 

This is a conversation I had with Jon White (@TechNurseJon) and Kelley Reep (@reepRN) about their new Twitter chats and the aims and objectives of them. We also wax lyrical about the benefits of Twitter as a whole!

Thomas Piraino (@respresource) kindly joined me to talk about a paper he had been involved in writing recently regarding the evidence behind APRV-  "Airway Pressure Release Ventialtion in patients with acute respiratory distress syndrome: not yet we still need more data!". I think it will make me less likely to use it in the future. 

One of my colleagues, Rachel Williams (@rawbubbles9), and her team are working very hard to get the patients moving and then hopefully home sooner whilst on the wards. This involves a number of methods including reindeer!

My contacts at the American Association of Critical Care Nurses put me in touch with Jill Guttormson, the author of Nurses’ Attitudes and Practices Related to Sedation: A National Survey.  It seems we are still not great at doing the sedation hold and this is an attempt to find out why. Some interesting points raised I think.

Paul uses this A-Z checklist for every patient on the ward round. Here he takes us through it to add to our understanding of some of the issues we need to consider when assessing our patients.

In this episode Bryan discusses some of the issues with pain, agitation and delirium with the pharmacist Komal Pandya. 

We all try to understand how to help our patients and sometimes get it wrong, but lets continue to work hard to improve.

Jakob SM, Ruokonen E, Grounds RM, et al. Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. Jama. 2012;307(11):1151-60.

https://www.ncbi.nlm.nih.gov/pubmed/22436955

Mehta S, Burry L, Cook D, et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. Jama. 2012;308(19):1985-92.

https://www.ncbi.nlm.nih.gov/pubmed/?term=mehta+2012+sedation+interuption

Pandharipande PP, Pun BT, Herr DL, et al. Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. Jama. 2007;298(22):2644-53.

https://www.ncbi.nlm.nih.gov/pubmed/18073360

Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. Jama. 2009;301(5):489-99.

https://www.ncbi.nlm.nih.gov/pubmed/?term=sedcom+2009

Shehabi Y, Howe BD, Bellomo R, et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. The New England journal of medicine. 2019;380(26):2506-17.

https://www.ncbi.nlm.nih.gov/pubmed/31112380

Sue Brierley Hobson is a dietitian in Wales and was part of a recent study looking into the efficacy of volume based feeding. We chat about this and the PERFect protocol.

Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Time' (PERFECT) protocol: a before-and-after study.

Dr Paul Hughes Webb chats with me about how we define aneamia and what we can do about it for our patients.

The last podcast from the NTI2019 and this was with other practitioners who all use Social Media to help others learn. This was a great conversation and a great way to wrap up. Thanks NTI I had a great time.

Maureen A Seckel chatted about some of the studies she had noticed over the last year related to sepsis and I then went on to discuss proning with Danette Mitchell and how she had implemented an education program in her unit.

Michael H Ackerman and Dr. Tom S. Ahrens chat with me about some of the recent changes in sepsis management. (Spoiler alert- not many to talk about!)

Brandy Venable and I discuss how we can utilise QR codes to create just in time learning for the staff in critical care.

What are the heamodynamics we should be concerned with and should we be measuring them?

Jason developed life threatening sepsis after catching the H1N1 virus. He spent a lot of time in ITU, but then decided to become an ITU nurse. This gives him a unique perspective.

@onlyintheicu is the twitter handle of a nurse who has experienced some mental health issues including an attempted suicide. She and I  discuss the implications of this increasing problem for ICU staff

Sometimes handing over our patients problems to another health care provider can be done badly not getting us the response we need. How can we improve that?

I finally met Sean Dent who posts very regularly on Facebook and Instagram and is also someone I follow and interact with on Twitter. We also chat with Sarah Wells who is trying to help new and junior nurses by supporting them via social media.

Nicole Kupchik presented some of the key studies of the last year. Here she covers some of them for us with Anna Rodriguez

Ruth Kleinpell, Teresa Rincon and Denise Ward chat with Bryan Boling about the development of Telehealth in The USA. 

Nicole presented on the implications of genetics on medicine management with our patients. Anna Rodriguez chats to her about it. Oh, and we finish with a Game of Thrones chat (no spoilers)

Jon White chats with Nancy and Gayle about what makes staffing levels safe and how we can ensure that we keep our staff healthy,

Bryan Boling chats with Daniel and Brandi about some of the liver problems our patients can have at the #NTI2019

Megan (@nursenoodles) is president elect at the conference this year and in this episode she chats with Jon (@technursejon) about her upcoming work, social media and how she got that Twitter name!