ICU Nurse Allocation in a Cardiothoracic ICU : How many Hands do we Need ?

Aim. To determine the nurse/patient ratios required to render safe; competent ICU nursing. Method. A patient classification system (CritScore) was used to compile an objective 3-month patient profile. The number (of full-time and agency staff) and the professional profiles of nursing staff allocated to the unit during this period were documented. Results. The majority of the patients were class 3 patients. While there was concordance between the total number of nurses present in relation to the number predicted by CritScore; the number of ICU-trained nurses was consistently below that ascertained by CritScore. This unit was staffed on average with more than 50 nonpermanent staff who were employed on a temporary basis via agencies. Conclusion. The number of nursing hands allocated is important; but even more so is the quality; or competence; of these hands. Nursing care without an acceptable level of competence in a critical care unit may be considered as a potentially harmful intrusion for the patient

HIV/AIDS: impact on maternal mortality at the Johannesburg Hospital, South Africa, 1995-2001.

This study investigated maternal mortality at the Johannesburg Hospital, a 1100-bed academic hospital in South Africa. Patient records were assessed retrospectively over two time periods: 1995/1996 and 2000/2001. Causes of death were noted and compared with national data. The two time periods were compared to identify disease patterns and the role of anaesthesia in maternal mortality. The maternal mortality ratios were respectively 183 and 354 per 100000 live births respectively. Hypertension in pregnancy was the leading cause of mortality in 1995/1996, accounting for 10 out of the 20 deaths, but was the second most common cause in 2000/2001 (6 out of 35). HIV/AIDS-associated disease was the leading cause of mortality in 2000/2001 (42.7%, increasing from 20% in 1995/1996) with pneumonia the commonest cause of death. The statistics at this hospital were consistent with the national trend of an increasing association with HIV/AIDS. No deaths were found to be directly attributable to anaesthesia in either of the time periods. There is a need for clearer documentation of HIV status in pregnancy and antiretroviral intervention strategies must be considered.

Ventilation and the critically ill parturient.

Positive-pressure ventilation is the keystone in the management of pulmonary dysfunction in the critically ill. An increased understanding of both the benefits and hazards has led to a general consensus regarding the optimal techniques to ensure adequate gas exchange. Unfortunately, the same cannot be said for ventilation terminology which, due to a lack of standardization, lends itself to confusion. Pulmonary dysfunction in the parturient may arise from thoracic or extra-thoracic pathologies but both may be defined as acute lung injury. In its most severe form this constitutes acute respiratory distress syndrome. Acute lung injury results in reduced lung compliance and a marked decrease in the volume of functional lung. Ventilation strategies are now designed to recruit as much available lung tissue as possible while simultaneously minimizing the injurious effects of alveolar over-distension. Upon resolution of the underlying pathology mechanical ventilation may be withdrawn. Recent evidence suggests that this final stage need not be protracted, and if certain criteria are fulfilled, rapid weaning is feasible.

Intensive care unit morbidity and mortality from eclampsia: an evaluation of the Acute Physiology and Chronic Health Evaluation II score and the Glasgow Coma Scale score.

OBJECTIVE: To determine the maternal morbidity and mortality in patients with eclampsia admitted to an intensive care unit (ICU), and to establish the efficacy of the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the organ system failure score as defined by Knaus, and the Glasgow Coma Scale (GCS) score in predicting outcome. DESIGN: Retrospective analysis of a 3.5-yr period. SETTING: Surgical ICU in a university hospital. PATIENTS: A total of 105 patients who were admitted with a diagnosis of eclampsia were studied. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The data captured included the reason for admission, maternal age, gestational age, parity, number of seizures, duration of ICU stay, anticonvulsant therapy, drug therapy, GCS score, APACHE II score, and the occurrence of organ failure. Of the 126 patients with eclampsia who were admitted to the ICU, records of 105 patients (83%) were found. The overall mortality was 10.5% (n = 11). The mean age, gestation, parity, number of preadmission seizures, and duration of stay were similar in survivors and nonsurvivors. Although the APACHE II score was significantly higher in nonsurvivors, multiple logistic regression analysis suggested that the goodness-of-fit scores for GCS and APACHE II were similar (38.29 vs. 38.01). The GCS scores of survivors were significantly higher than those of nonsurvivors (10.61 vs. 5.0; p<.001). Respiratory failure was the most common organ failure in both groups. The mean number of organ failures was higher in nonsurvivors compared with survivors (2.9 vs. 1.3; p<.001). An occurrence of more than two organ failures that persisted for >48 hrs was invariably associated with a fatal outcome. Anticonvulsant therapy consisted of magnesium sulfate or phenytoin and a midazolam infusion. Only one patient (0.9%) had a seizure, and this occurred en route to the ICU. No seizures occurred after admission to the ICU. CONCLUSIONS: The organ system failure score and the GCS score are good predictors of outcome in eclampsia. Apart from the GCS score, other variables in the APACHE II score are not valuable for outcome prediction. The low GCS score in nonsurvivors suggests that closer attention to the neurologic management may be beneficial. A prospective study is indicated to validate these findings.

Management of sympathetic overactivity in tetanus with epidural bupivacaine and sufentanil: experience with 11 patients.

OBJECTIVE: To determine the efficacy and safety of epidural bupivacaine and sufentanil for the management of sympathetic overactivity in tetanus. DESIGN: Retrospective case review. SETTING: Sixteen-bed surgical intensive care unit in a tertiary care centre. PATIENTS: All patients referred to the unit during a 63-month period with the diagnosis of tetanus were included in the study. MEASUREMENTS AND MAIN RESULTS: All patients (n = 11) had severe tetanus and developed sympathetic overactivity, which was managed by epidural blockade. Three patients died, but there were no fatalities directly attributable to sympathetic overactivity. Before epidural blockade, the average difference between the mean maximum and mean minimum systolic blood pressures was 78 +/- 28 (so) mm Hg. After blockade, this difference was reduced to 38 +/- 15 (so) mm Hg (p < .0001). Similar significant reductions in diastolic blood pressure and heart rate were observed. The mean hourly infusion doses of bupivacaine and sufentanil were 17 mg and 21 microg, respectively. Midazolam was the principal adjunctive sedative agent and was used in all patients (mean dose, 9 mg/hr). Additional pharmacologic agents were necessary in two patients in whom epidural blockade alone was insufficient to control sympathetic overactivity. One patient developed renal failure and there were no instances of pneumothorax. One patient developed an epidural abscess of probable hematogenous origin, which was successfully treated without neurologic sequelae. CONCLUSIONS: Epidural blockade is effective in controlling sympathetic overactivity and the associated complications (renal failure, cardiac injury, and sudden death). Although a serious complication occurred in one patient, the efficacy of the technique deserves further validation.

Patterns of injury and white cell response in critically ill trauma patients who present with leucopenia.

The outcome of critically ill trauma patients who presented to the intensive care unit with leucopenia (total peripheral white cell count < 4 x 10(9)/1) was studied prospectively with respect to the total white cell and neutrophil response. A total of 105 patients, of whom 30 were leucopenic, were admitted to the ICU during a 4-month period. The prevalence of leucopenia was significantly higher in patients with gunshot wounds (P < 0.05) and hollow visceral intra-abdominal injury (P < 0.001). Eight (27%) of the leucopenic patients died. No significant difference was found in initial mean total white cell or neutrophil count, or in the differential percentages, between survivors and non-survivors. The total peripheral white cell count increased significantly in survivors compared with non-survivors (P < 0.001), and significant differences were found in absolute neutrophil counts and differential percentages by days 5 and 10 (counts P = 0.01, P < 0.02; differentials P < 0.01, P < 0.01). These results suggest that granulocyte colony-stimulating factor may have a role in the treatment of trauma patients with persistent neutropenia following intra-abdominal hollow visceral injury.

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients.

OBJECTIVES: To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patients without head injury, and their relationships to mechanism of injury, Acute Physiology and Chronic Health Evaluation (APACHE) II score, risk of death, Injury Severity Score (ISS), number of organ failures, and mortality rate. DESIGN: Prospective, inception cohort analysis. SETTING: Sixteen-bed surgical ICU in a teaching hospital. PATIENTS: Four hundred fifty critically injured patients without associated head trauma. Penetrating trauma accounted for 70% (gunshot 202; stab 113) and nonpenetrating trauma for 30% (motor vehicle collision 103; blunt 32) of admissions. Three hundred ninety-four (88%) patients underwent surgical procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Infective and noninfective insults were distinguished by the need for therapeutic or prophylactic antibiotics, respectively, based on an established antibiotic policy. Three hundred ninety-five (87.8%) patients fulfilled a definition of the SIRS criteria. The frequency of the definitive categories was SIRS 21.8%, sepsis 14.4%, severe SIRS 8.4%, severe sepsis 13.6%, sterile shock 9.3%, and septic shock 20.2%. Patients with penetrating trauma had a significantly higher frequency of sepsis, severe sepsis, and septic shock (p < .01). The APACHE II score, risk of death, and number of organ failures increased significantly in both infective and noninfective groups with increasing severity of the inflammatory response. Sterile shock was associated with a significantly higher APACHE II score (p < .02), risk of death (p < .01), and number of organ failures (p = .03) compared with septic shock. Only sterile shock was associated with a significantly higher ISS (p < .01). Organ system failure was significantly (p < .001) higher in nonsurvivors compared with survivors in all categories. The only significant (p < .001) difference in mortality rate was found between patients in shock and all other categories. CONCLUSIONS: The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction. The only significant association with mortality, however, is the presence of shock. The definitions require refinement, with the possible inclusion of more objective gradations of organ system failure, if they are to be used for stratifying severity of illness in seriously injured patients.

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study.

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.

Validation of an outcome prediction model for critically ill trauma patients without head injury.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) II system is inaccurate in predicting the risk of death in trauma patients, especially those without head injury. Using multivariate analysis of the APACHE II system in a development set, a new predictive equation was modeled. The four variables that were independently associated with mortality were PaO2/FiO2 ratio, mean arterial pressure, temperature, and the need for inotropic support. This model was tested prospectively in an independent validation set of 300 patients. METHODS: Risk of death was calculated using the APACHE II system with the diagnostic category of multiple trauma and weighting for operative intervention as required. The new model was similarly assessed using the four predictor variables and their beta-coefficients for each mechanism of injury and the entire group. The predicted risk of death derived by both models was compared with the observed mortality rate. Discrimination was calculated using a 2 x 2 decision matrix with a decision threshold of r = 0.5 and receiver operating characteristic curves. Calibration was assessed graphically and by statistical correlation. RESULTS: The observed mortality rate was 28.3% and the predicted mortality risk was 27.4% for the model and 6.26% for APACHE II. The sensitivity and specificity of the model were 58.8 and 90.7%, and the sensitivity and specificity of APACHE II were 1.2 and 100%. The areas under the receiver operating characteristic curves were 0.84 and 0.78 for the model and the APACHE II system, respectively. Calibration of the model was superior within all deciles of risk (model, R2 = 0.93, p < 0.001; APACHE II, R2 = 0.82, p = 0.02). CONCLUSION: The model accurately predicted the risk of death for the entire group. It is superior to the APACHE II system and is the highest reported sensitivity for 24-hour intensive care unit predictive models that have been applied to the critically injured.

Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU.

OBJECTIVE: To determine a) if clinical examination can accurately predict radiological change and b) if routine chest radiography is efficacious. DESIGN: All mechanically ventilated patients admitted to the Surgical Intensive Care Unit over a 4-week period were enrolled into the study. A physical examination was undertaken by two clinicians to predict significant (radiographic features which alter management) and insignificant (radiographic features which do not alter management) changes. The radiographs were then reviewed by a radiologist who noted any changes from previous radiographs. The clinical findings were then correlated with the radiographical findings. SETTING: The study was conducted in a 16-bedded Surgical Intensive Care Unit which admits approximately 800 patients per year. The majority of these patients require mechanical ventilation. PATIENTS AND PARTICIPANTS: All patients who required mechanical ventilation were included. Thirty-four patients were studied. The patients were young adults admitted primarily following trauma with a low incidence of pre-existing disease. INTERVENTIONS: There were no interventions in this study. MEASUREMENTS AND RESULTS: One hundred sixty-four radiographs were evaluated. Both examiners were efficient in predicting significant changes (sensitivity of 93 and 97%), but less efficient at predicting insignificant changes (sensitivity of 74 and 70%). Two significant radiographical changes were missed on clinical examination: one catheter malposition and one pneumothorax, representing a yield from radiography of 1%. A 52% reduction in the number of radiographs would have resulted if the need for radiography had been determined by clinical examination. CONCLUSIONS: Clinical examination can effectively predict the need for radiography. Routine chest radiography is, therefore, not indicated for ventilated patients in our Surgical Intensive Care Unit.

Prediction of the risk of death by APACHE II scoring in critically ill trauma patients without head injury.

The ability of the Acute Physiology And Chronic Health Evaluation (APACHE) II scoring system to predict outcome in 199 critically ill patients with trauma but without head injury was assessed prospectively over an 8-month period. Some 178 patients (89.4 per cent) underwent operation and 50 (25.1 per cent) died, 44 after operation and six without undergoing surgery. The mean(s.d.) APACHE II score was 8.0(5.2) for survivors and 14.5(5.5) for non-survivors (P < 0.001). In patients who underwent surgery the mean(s.d.) scores were 7.7(4.6) and 13.4(5.5) (P < 0.001) and for those managed without operation 11.1(7.2) and 14.7(6.3) (P = 0.31) in survivors and non-survivors respectively. The predicted risk of death and observed mortality rate were 5.1 and 25.1 per cent respectively for the entire group, 5 and 25 per cent for patients undergoing surgery, and 7 and 29 per cent for those not operated on. Although the APACHE II system correctly identified all survivors (specificity 100 per cent), it failed to predict death in any patient (sensitivity 0 per cent). The results suggest that this objective prognostic scoring system is not applicable to the patient with trauma who does not have concurrent head injury.

Prospective, controlled study of the outcome of human immunodeficiency virus-1 antibody-positive children admitted to an intensive care unit.

OBJECTIVE: Intensive care resources are both scarce and costly in South Africa. We set out to ascertain whether human immunodeficiency virus (HIV) status affects the spectrum of disease and the prognosis in children treated in pediatric intensive care units (ICUs). DESIGN: A prospective, case-controlled study. SETTING: The pediatric ICU at Kind Edward VIII Hospital, Durban, South Africa. PATIENTS: HIV-positive cases were classified as "acquired immunodeficiency syndrome," "symptomatic HIV," and "HIV-unrelated diseases." Controls were matched for age, race, gender, severity of disease, and admitting diagnosis. MEASUREMENTS AND MAIN RESULTS: THe clinician was blinded to the serostatus of patients. Informed consent and Ethics Committee approval were obtained for HIV testing and the study. Outcome measures were the duration of intermittent positive-pressure ventilation and ICU stay, maximum ventilatory requirements, infectious complications, and mortality. There were 11 cases of acquired immune deficiency (AIDS), 24 cases of symptomatic HIV, and 13 cases of HIV-unrelated diseases. Mortality rates for the three groups were as follows: 100% in patients with AIDS compared with 55% in their controls (p<.01); 38% in patients with symptomatic HIV and 46% in controls. Cytomegalovirus and Pneumocystis carinii infections were significantly increased (p<.01, p<.002, respectively) in patients with AIDS as compared with controls. Outcome measures were similar in those patients with symptomatic HIV and those patients with HIV-unrelated diseases, as compared with their respective controls. CONCLUSIONS: Outcome in children with AIDS admitted to the pediatric ICU was significantly worse than the outcome in HIV-uninfected children. However, the number of AIDS patients studied was small. HIV antibody-positive children without AIDS do as well as uninfected controls. Ethics committees in resource-constrained countries may be assisted by such data when making difficult decisions on the admissions of HIV-infected patients to pediatric ICU facilities.

Adverse events in a surgical intensive care unit--a cause of increased mortality.

The incidence and nature of and the outcome following adverse events were studied prospectively in a surgical intensive care unit over a period of 1 year. From a total of 657 patients, 229 (34.8%) suffered 369 adverse events. The number of adverse events per patient ranged from 1 (58.1%) to a maximum of 4 (6.1%). The overall mortality rate was 23.4%. Eighty-seven deaths (20.3%) occurred in patients not suffering an adverse event and 67 (29.3%) in those whose treatment was complicated by an adverse event (P < 0.02). There was no significant difference in mortality between patients with single or multiple events. Twenty-two patients died as a direct result of the event, the commonest reason being loss of airway control. Adverse events contribute significantly to mortality in critically ill patients.

Prevention of hypotension following spinal anaesthesia for elective caesarean section by wrapping of the legs.

Twenty-four parturients undergoing elective Caesarean section were allocated randomly to have the legs wrapped with elasticated Esmarch bandages immediately following spinal anaesthesia or to serve as controls. Significant hypotension (systolic arterial pressure less than 100 mm Hg and less than 80% of baseline value) was treated with i.v. ephedrine in 5-mg boluses. Leg wrapped patients had a significantly (P = 0.0033) lower incidence (16.7%) of hypotension than controls (83.3%). Only two patients in the leg wrapped group required ephedrine compared with 10 in the control group. Systolic arterial pressure was significantly (P less than 0.05) less in control subjects at 4, 5 and 6 min following spinal injection. No patient in the leg wrapped group became hypotensive following removal of the elasticated bandages.