Intermittent enteral nutrition--a comparative study examining the effect on gastric pH and microbial colonization rates.

In a prospective randomized study we aimed to examine the effect on gastric pH and microbial colonization of enteral nutrition (EN) delivered both by intermittent and continual infusion. Forty-three mechanically ventilated patients were randomized to receive EN by one of three methods, intermittent or continual gastric or continual jejunal. We sampled gastric aspirate for pH and culture in all patients at 0600 hours and pH in gastric intermittent feeders at 2200 hours daily. Patients were studied for 12 days or until extubated. Data was obtained on 41 patients, of whom 73% had a diagnosis of trauma. Median APACHE II score was 17 and ventilation time 11 days. Twelve patients received gastric continuous, 15 gastric intermittent and 14 jejunal nutrition. No significant difference was observed between the three groups with regard to median 0600 pH (P = 0.16). This was lowest in the jejunal group (3.2) followed by the gastric intermittent group (4.0) and then gastric continuous group (5.0). With overnight cessation of EN in the gastric intermittent group, the median pH fell from 5.2 at 2200 to 4.0 at 0600 (P = 0.01) with no effect on gastric colonization. The probability of gastric colonization over time however was significantly lower in the jejunal group compared with the two gastric groups (Log rank test, P = 0.02). These results demonstrate that in a patient population consisting predominantly of trauma, overnight cessation of EN made no overall difference to 0600 gastric pH or colonization rates. The preservation of pH and lowered colonization in those given jejunal feeding may have implications in the pathogenesis of ventilator-associated infection and may warrant further study using larger patient numbers.

Hepatic and renal failure associated with amiodarone infusion in a patient with hereditary fructose intolerance.

Hereditary fructose intolerance is a rare inherited metabolic disorder. Although fructose intolerance usually presents in the paediatric age group, individuals can survive into adulthood by self.manipulation of diet. Hospitalisation can become a high.risk environment for these individuals because of loss of control of their strict dietary constraints and the added danger of administration of medications containing fructose, sucrose and sorbitol. We report a case of hereditary fructose intolerance in an adult presenting with hepatic and renal failure associated with an amiodarone infusion and explore the possibility of polysorbate 80 as a cause of this patient's hepatic and renal failure.

Complete practice operating systems: the long-term solution to practice management.

A carefully structured, well thought-out CPOS based on a successful prototype(s) that has proven itself over time is probably the fastest and most reliable way to get your practice on the road to profitability that can be sustained and built upon over the life of the practice. If you rely on "bits and pieces" of practice management ideas and extraneous methods that of themselves may be effective, they may, when integrated into your existing operating structure or system, actually have a negative impact. When addressing something as important as your practice operations, and hence, your livelihood, carefully determine if the changes advocated will be effective, and how these changes will interface with your existing systems. If your existing systems are faulty, building on them may be futile. Look closely and carefully examine the knowledge, credibility, and expertise of anyone who is suggesting and implementing change in your practice. Further, and equally important, ask these two questions: (1) Is the operating system you are considering designed and built from a successful prototype? (2) Can the system's success be documented in terms of sustained increase in production, collections, and net income over time? If the answer is "no" to either or both of the above, tread lightly. You may actually be making things worse. Look for an operating system that has made other dental practices successful, and you can have the great practice you've always wanted!

Psychosocial functioning during the year following severe traumatic brain injury.

The psychosocial functioning of a group of 65 adults with severe traumatic brain injury was assessed at 6 months and 1 year post-injury. Aspects of emotional, behavioural, and social functioning were investigated. The prevalence of depression remained constant (24%) over time, although there was some individual variation in the reporting of symptoms. Impatience was the most frequently reported behavioural problem at both assessments. Whilst there was a slight increase in the number of behavioural problems and level of distress reported over time, the most obvious change was in the type of behavioural problems that caused distress. At 1 year post-injury, problems with emotional control were found to be most distressing for the patients. A comparison with pre-morbid social functioning showed the loss of employment to be 70%, 30% returned to live with their parents, and relationship breakdown occurred for 38%. There was also a significant and ongoing decrease in all five aspects of social and leisure activities.

Neuropsychological functioning during the year following severe traumatic brain injury.

The neuropsychological functioning of a group of 65 adults with severe traumatic brain injury was assessed at 6 months and 1 year post-injury. The cognitive domains assessed were pre-morbid intellectual level, current level of general intellectual functioning, simple and complex attention, verbal memory, executive functioning, and perceptual functioning. At least 40%, and up to 74%, of the TBI patients displayed some degree of impairment on tests administered at 6 months. Improvement was found to occur in all areas of cognitive functioning over the first year following injury. Despite this improvement at least 31%, and up to 63%, of TBI patients displayed some degree of impairment on tests administered at 1 year post-injury. The various types of neuropsychological functioning were affected to different degrees, indicating that different aspects of cognition are more susceptible to injury, and that recovery takes place at a differential rate across functions. The implications of these findings for the appropriate planning and allocation of treatment and rehabilitation resources, and the development of effective rehabilitation interventions are outlined.

Written guidelines for laboratory testing in intensive care--still effective after 3 years.

OBJECTIVE: The aim of the study was to examine the effect of time on written guidelines for laboratory testing in an intensive care unit by comparing the numbers of tests performed with those performed three years previously. METHODS: In 1995, guidelines were developed for blood test ordering in the Waikato Hospital intensive care unit, which when implemented resulted in a decrease in all blood tests performed by 16.6% in a group of general intensive care patients and by 25.9% in a group of post cardiac surgery patients. We repeated this study on similar groups of patients to see if the guidelines were still effective. Data on age, APACHE II score, diagnosis, and ventilation time were collected. Comparisons were made of tests performed per patient and per ventilation time in hours. RESULTS: In the general intensive care patient group, there was an increase of 2.1% tests performed per patient, but a decrease in tests performed per ventilation time of 5.6%. In the postoperative cardiac surgery patient group, the total number of tests performed per ventilation time decreased by 4%. The arterial blood gases performed per patient increased by 10.7% in the general intensive care patient group, and decreased by 14.3% in the postoperative cardiac surgery patient group. However, when the number of arterial blood gases performed per ventilation time were compared with the 1995 study, there was no difference in the general intensive care patient group, while there was a reduction by 8.3% in the postoperative cardiac surgery patient group. CONCLUSIONS: Three years after the implementation of guidelines for laboratory testing in an intensive care unit, there was no return to the level of testing recorded before the guidelines were introduced. The number of tests per ventilation time decreased by 4% in postoperative cardiac surgery patients and decreased by 5.6% in the general intensive care patients. In our study written guidelines remained effective three years after their introduction.

Observer error and prediction of outcome--grading of head injury based on computerised tomography.

OBJECTIVE: To measure inter-observer error of a recently reported computerised tomography scoring system and to assess the ability of the scoring system to predict outcome in head injury patients. METHODS: Two radiologists independently graded all CT scans performed during the admission of all head injured patients. They were blinded to the clinical condition of the patient. Patients were followed up at 12 months and given a Glasgow outcome score. Outcomes were matched to the 2 independent assessments done on the first CT scan for each patient. RESULTS: A total of 123 head injury patients were studied. For the diffuse injury categories, there were 410 gradings made. Of these, 32% differed by at least one category. Where at least one of the radiologists identified non-evacuated mass lesions there were 148 gradings. Of these, one radiologist reported an un-evacuated mass lesion in 47%, which was not reported by the other. The first CT scan was evaluated on 119 patients. Using the Chi-Squared test, the diffuse injury IV category was the only one to show a strong relationship with outcome as measured by the Glasgow outcome score. CONCLUSIONS: The prediction of outcome for head injury patients based on CT scans has significant shortcomings. In our study, there was significant variation in grading by experienced radiologists. The separate categories were also poor predictors of outcome at 12 months except for diffuse injury IV. The classification of mass lesions needs modification to be useful.

Isolated ventricular septal defect secondary to low-velocity blunt chest trauma.

Damage to the ventricular septum resulting from low velocity blunt trauma to the anterior chest wall is a rarely reported disorder. We wish to report a case of an isolated large ventricular septal defect secondary to blunt chest trauma requiring urgent surgical repair in an otherWise healthy 19 year old male. The patient endured a long hospital stay complicated by repeated episodes of pulmonary oedema and ARDS but eventually made a good recovery.

Cognitive and psychosocial outcome in survivors of severe traumatic brain injury: correlations with cerebral perfusion pressure, frontal lobe damage and somatosensory evoked potentials.

OBJECTIVE: To correlate neuropsychological outcome in patients after severe traumatic head injury, with neurophysiological and neuroradiological data collected during the intensive care unit (ICU) period of care. METHODS: Patients admitted to Waikato Hospital ICU with severe traumatic head injury were studied. Respiratory difficulty at the accident site, admission Glasgow Coma Score (GCS), anatomic traumatic brain disruption as quantified by a cerebral computed tomography score, prolongation of the central conduction time (CCT) of somatosensory evoked potentials and the percentage time that the cerebral perfusion pressure was less than 70 mmHg (%CPP < 70) were measured. Neuropsychological outcome was assessed, in terms of cognitive and behavioural function, by the Controlled Oral Word Association (COWA) test (performed by the patient) and Head Injury Behaviour rating scale (HIBS, performed by their caregiver) respectively, one year following injury. RESULTS: Sixty-eight patients with a median post-resuscitation GCS of 6 were able to complete the neuropsychological follow up. Most patients had significantly impaired cognitive and behavioural function (mean COWA = 32 and HIBS = 9.7). Cognitive function did not correlate significantly with behavioural function (COWA vs HIBS, r = -0.14, p = 0.27). There were no significant correlations between either GCS (r = 0.15, p = 0.28) or estimates of respiratory difficulty at the accident scene and neuropsychological outcome. Poor cognitive outcome (COWA) was correlated with %CPP < 70 (r =-0.41, p = 0.005) and prolonged CCT (r = 0.26, p = 0.03). There was an insignificant correlation between the CT score and cognitive outcome (frontal lobe score vs COWA, r = -0.12, p = 0.33). However, the group of patients with the most severe frontal lobe injury tended to have a worse behavioural outcome as assessed by the HIBS. CONCLUSIONS: Behavioural outcome as quantified by the caregiver (HIBS) does not correlate well with the degree of cognitive impairment as measured directly from the patient (COWA). Severely head injured patients with poor neurophysiological indicators (%CPP < 70 or prolonged CCT) have a poor neuropsychological outcome. However, anatomical disruption of the brain as estimated by the frontal lobe CT score correlated poorly with outcome.

Somatosensory evoked potentials in severe traumatic brain injury: a blinded study.

OBJECT: Beginning in 1979, the results of somatosensory evoked potential (SSEP) monitoring have been used to predict outcome in patients who have suffered severe brain trauma. The data indicate that if the cortical components of the SSEPs were bilaterally absent, the outcome was always death or a vegetative state, but previous studies have not been blinded. The aims of this study were to correlate the results of SSEP recordings with the outcome in a prospectively blinded manner and to assess whether monitoring of SSEPs was a useful adjunct to clinical judgment in the prediction of outcome. METHODS: The authors studied 105 severely head injured patients (median Glasgow Coma Scale score of 6) who were admitted to the Waikato Intensive Care Unit. The upper limb SSEPs were classified according to the central conduction time (CCT) as normal, of increased latency, or absent. The outcome as assessed using the Glasgow Outcome Scale (GOS) score was evaluated 12 months after the injury. CONCLUSIONS: Of 51 patients with a bilaterally normal CCT, 29 (57%) had a good outcome (GOS Score 5). Any delay in CCT was associated with a decreased incidence of good outcome (30%). Unilateral absence of the cortical component of the SSEP was usually associated with a poor outcome (death or severe disability), and bilateral absence was always associated with a poor outcome. The authors conclude that SSEPs correlate well with outcome and that this is not the result of investigator bias.

An audit of deaths occurring in hospital after discharge from the intensive care unit.

The aim of the study was to conduct an audit of patients who died in the ward after discharge from the intensive care unit (ICU). Clinical records of those who died in the ward following discharge between 1991 and 1997 were reviewed. Patients were retrospectively grouped according to whether death was expected, unexpected or likely to die within one year. The causes of death, times in ICU and hospital, demographics, and APACHE II scores were compared. Ninety-nine patients were studied, of whom 60 were triaged to the ward expected to die at the time of ICU discharge. Five of the patients were classified as not expected to die. Of the remaining 34 patients, 65% were debilitated with more than one organ disease and 62% eventually had some treatment withdrawn on the ward. After discharge from ICU, no obvious ward treatment deficiencies were found to contribute to death. However, of those who were admitted to the ICU from the ward and who later died when back in the ward, there seemed to be avoidable events pre-ICU admission in eight (36%) patients, some of which may have contributed to the later death of the patient.

Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients.

OBJECTIVE: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. DESIGN: One-year prospective audit. SETTING: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. PATIENTS AND PARTICIPANTS: 400 patients with non-tunnelled CVCs. INTERVENTIONS: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. MEASUREMENTS AND RESULTS: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8%) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95% confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. CONCLUSIONS: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population.

The place of the high dependency unit in a modern New Zealand hospital.

AIM: To describe the concept of, and the benefits which come from having, a high dependency unit (HDU), based on the 24 years experience of Waikato Hospital. DESCRIPTION: The HDU (9 beds/1600 patients per year) is part of the Critical Care Unit which also contains an adult intensive care unit (ICU) (11 beds/1000 patients per year), and a paediatric ICU/HDU (3 beds/250 patients per year). The regular care in the HDU is given by the specialist teams, aided by input from the ICU team. Over three years, 4390 patients were admitted having an average stay of 34 hours (61% < 24 hours). Forty eight percent of patients were over 60 years of age. The main sources of admissions were the theatre (66%), emergency department (18%), ICU (14%) and wards (11%). The main destinations were the wards (92%) and ICU (4%), with a mortality of 0.6%. The reasons for admission, specialist teams and post-operative diagnoses are described. Clinicians value the area highly, and have used it extensively. The average cost was $NZ800 per day. CONCLUSIONS: Large hospitals in New Zealand should be planning an HDU to allow adequate care for those patients too complicated for the ward but not needing the ICU. Smaller hospitals can usefully combine the functions of ICU and HDU within one area.

Profile and cost of head injury patients admitted to the Waikato Hospital Intensive Care Unit.

AIMS: To examine the profile and hospital costs of head injury patients admitted to the Waikato Hospital Intensive Care Unit (ICU). METHODS: Data were collected on head injury patients admitted to ICU over 41 months and costs of head injury patients in ICU, the High Dependency Unit (HDU) and other wards were calculated. RESULTS: There were 286 head injury patients admitted to ICU, of whom 62% had a Glasgow Coma Score < or = 8. Times in the ICU and hospital were 1760 and 7352 days respectively. Costs per day were $2280 in ICU, $800 in HDU and $500 in other wards. The cost for ICU was $1,174,478 per year, and for the total hospital treatment, $2.05 million (83 head injury patients) per year. Admissions of head injury patients to all New Zealand ICUs were 777 over the year to June 1996. Thus, assuming similar costs to the Waikato Hospital, New Zealand hospitals spend each year approximately 10.9 million dollars on head injury patients in ICUs and 19 million dollars on overall hospital stays (including ICU). In a selected group of 123 severe head injury patients, the six month Glasgow Outcome Scores showed that 36% were in the moderate to severe disability categories and likely to cause major ongoing ACC costs. The costs of the 80% of head injury patients admitted to hospital but not admitted to ICU, and their prehospital and postdischarge costs were not studied. CONCLUSIONS: The New Zealand epidemic of head injuries continues to consume large amounts of the health money and produce major social costs.

Caregiver burden at 6 months following severe traumatic brain injury.

Sixty-nine primary caregivers of people with a severe traumatic brain injury (TBI) were assessed at 6 months post injury. Caregivers completed questionnaires on the physical, cognitive, emotional, behavioural, and social functioning of the persons with the TBI. Caregiver psychosocial functioning and levels of subjective and objective burden were also assessed. Clinically significant levels of anxiety, depression, and impairment in social adjustment were evident in over a third of the caregivers. The frequency with which various changes in the person with the TBI and types of objective burden were reported had little relationship to the degree of distress caused by these changes. The person with TBI's social isolation and negative emotional behaviours caused the greatest degree of stress for caregivers. Caregivers were also most distressed by the impact that caregiving had on their personal health and free time. The results from a multiple regression analysis suggest that it is the presence of behavioural problems in the person with the TBI that has the most severe and pervasive impact on all aspects of caregiver functioning. It is suggested that these findings be taken into account when providing rehabilitation services to people with TBI and their families.

Microbial contamination of three-way taps on arterial lines.

Arterial lines with three-way taps are used to measure blood pressure and aspirate blood, and are a potential source of catheter-related sepsis. Swabs were taken daily from 118 three-way taps on 98 arterial lines in a general intensive care unit. Infusion lines were changed weekly but arterial cannulae were not changed routinely. An overall contamination rate of 24.6% was found with the predominant organism being coagulase negative staphylococcus. The three-way taps became increasingly contaminated with time but this was shown to be unrelated to the manipulation rates. Blood culture organisms in those showing contamination of the three-way taps showed no relationship to the bacteria causing the contamination.

Management and outcomes of patients with brain trauma in a tertiary referral trauma hospital without neurosurgeons on site.

Waikato Hospital is a tertiary hospital of over 700 beds receiving large numbers of trauma patients, but has no neurosurgeon closer than 130 kilometres. Over the 10 years ending July 1997, 831 cases of brain trauma were admitted to the Intensive Care Unit. Of these, 191 died before leaving hospital (overall mortality 23%). Of the 547 who had a Glasgow Coma Score (GCS) < or = 8, 173 died (mortality 32%). Of the children who were < 15 years of age and had a GCS < or = 8, there was a 23% mortality. These mortality rates are acceptable when compared with other reports (average 37%, over 12 adult series). Using brain AIS scores, our mortality figures also compared favorably with those in the literature, and suggest that the quality of brain trauma care is adequate in this non-neurosurgical centre with intensive care, backed by CT scanning and general surgeons able to do urgent burr holes. Six percent of the brain trauma patients (approximately five per year), required interhospital transfer for definitive neurosurgical care.