The utility of hyperlactataemia in the definition of septic shock: evaluating the Sepsis-3 definitions in a sub-Saharan African intensive care unit

Background. Sepsis-3 definitions were published in 2016 and included hyperlactataemia (serum lactate >2.0 mmol/L) as a mandatory component of the new definition of septic shock. These data were collected mainly from high-income countries and lack adequate validation in scenarios outside these countries.Objectives. To evaluate admission serum lactate as a predictor of intensive care unit (ICU) mortality in patients with infection and hypotension requiring inotropic support.Methods. This was a retrospective observational study of 170 patients with infection and hypotension requiring inotropic support admitted to the ICU at King Edward VIII Hospital in Durban, South Africa. Admission serum lactate was evaluated as a predictor of ICU mortality in this cohort.Results. The study population had a median age of only 42 years. The ICU mortality rate for the cohort was 49.4%. Most patients were surgical (71.8%), with the most common source of sepsis being abdominal (55.9%). The ICU mortality rate was 40.9% in patients with a lactate level ≤2.0 mmol/L and 52.4% in those with a level >2.0 mmol/L; this did not reach statistical significance. The optimal cut-off was 4.5 mmol/L, at which there was a clear, statistically significant difference in mortality between patients without (39.3%) and with hyperlactataemia (59.3%)(p=0.009).Conclusions. Hyperlactataemia was associated with increased mortality. However, a lactate level >2.0 mmol/l, as proposed in Sepsis-3, did not reach statistical significance, and a higher cut-off of >4.5 mmol/L was more appropriate

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit

Background. When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context.Objectives. To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care.Methods. A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors.Results. A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease.Conclusions. A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital ­ a 4-year retrospective review

Background. Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients. Objectives. To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith. Methods. The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death). Results. The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia. Conclusion. The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management

Hypoxaemia on Arrival in a Multidisciplinary Intensive Care Unit

BACKGROUND:Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is; however; potentially preventable.OBJECTIVE:To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication.METHOD:A retrospective observational study was conducted at King Edward VIII Hospital; Durban; South Africa; from May 2013 to February 2014.RESULTS:Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (petlt;0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring; transfer by an intern as opposed to other medical/paramedical staff; and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02).CONCLUSION: Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring