The need for a regional weaning centre, a one-year survey of intensive care weaning delay in the Northern Region of England.

Over a period of one year, a weekly telephone survey identified 161 stable patients with weaning delay (defined as patients ventilated for at least 6 h per day for more than 2 weeks) in intensive care units in the Northern Region of England. Their median age was 69 years (range 21-88 years). Sixty patients (37%) were admitted with medical conditions, 89 (55%) were postoperative patients, whereas 12 (8%) were surgical but required non-operative admission. One hundred and thirty (89%) were weaned and discharged from the intensive care unit during the year. Twenty-two (14%) died and two were transferred to the home ventilation service. Seven patients remained ventilated in intensive care at the end of the study period. Twenty patients (12%) required more than 28 days of respiratory support. These patients occupied on average 6.0% of available intensive care unit beds in the region. This study suggests that in the Northern Region of England there are a significant number of stable but ventilator-dependent patients occupying intensive care beds.

The incidence of hydroxyethyl starch-associated pruritus.

BACKGROUND: Pruritus due to hydroxyethyl starch (HES) is reported with a very variable frequency but appears to be relatively uncommon in the U.K. compared with other European countries. OBJECTIVES: To determine the frequency of HES-related pruritus in patients discharged from intensive care units (ICUs) in two U.K. hospitals. METHODS: A questionnaire survey was given to 253 patients after discharge from ICU. Questions were designed to exclude pre-existing skin disease and other causes of pruritus. RESULTS: One hundred and fifty-nine completed questionnaires were suitable for analysis. Seventeen of 135 (12.6%) subjects who had received HES reported itch, as did one of 24 who had not received HES. There was no apparent relationship between the occurrence of HES-related pruritus and either the surgical indication or the brand or volume of HES infused. CONCLUSIONS: HES-related pruritus is a problem that dermatologists need to recognize; however, its frequency in the U.K., when other causes of itch are excluded, appears to be lower than suggested in some previous reported studies.

Intensive care: preparations for the Millennium. A survey of hospitals in the north of England.

In order to assess preparedness for the Millennium, we carried out a telephone survey of all Intensive Care Units in the former Northern Region. The survey disclosed wide variation in the current and planned provision of back-up power and central services, proposed staffing levels and expected demand.

Pulmonary oedema after peribulbar block.

Local anaesthesia is now preferred for cataract surgery. Respiratory distress caused by pulmonary oedema is a rare, if well recognized, complication of the technique of retrobulbar block. We report this complication after the increasingly favoured peribulbar approach.

As seen on TV: observational study of cardiopulmonary resuscitation in British television medical dramas.

OBJECTIVE: To determine the frequency and accuracy with which cardiopulmonary resuscitation is portrayed in British television medical dramas. DESIGN: Observational study. SUBJECTS: 64 episodes of three major British television medical dramas: Casualty, Cardiac Arrest, and Medics. MAIN OUTCOME MEASURES: Frequency of cardiopulmonary resuscitation shown on television; age, sex, and diagnosis of the patients undergoing resuscitation; rate of survival through resuscitation. RESULTS: Overall 52 patients had a cardiorespiratory arrest on screen and 3 had a respiratory arrest alone, all the arrests occurring in 40 of the 64 episodes. Of the 52 patients having cardiorespiratory arrest, 32 (62%) underwent an attempt at cardiopulmonary resuscitation; 8 attempts were successful. All 3 of the patients having respiratory arrests alone received ventilatory support and survived. On 48% of occasions, victims of cardiac arrest seemed to be less than 35 years old. CONCLUSIONS: Cardiorespiratory resuscitation is often depicted in British television medical dramas. Patients portrayed receiving resuscitation are likely to be in a younger age group than in real life. Though the reasons for resuscitation are more varied and more often associated with trauma than in reality, the overall success rate is nevertheless realistic. Widespread overoptimism of patients for survival after resuscitation cannot necessarily be blamed on British television medical dramas.

All that wheezes is not asthma. Paradoxical vocal cord movement presenting as severe acute asthma requiring ventilatory support.

A 23-year-old female presented with an acute exacerbation of her asthma, for which she required ventilatory support. Her wheeze disappeared immediately following tracheal intubation and ventilatory support was achieved with low airway pressures. We believe that the diagnosis of status asthmaticus was incorrect and that the patient was suffering from vocal cord dysfunction. We review reports of this condition and suggest that, in asthma, the expiratory flow limitation due to paradoxical vocal cord movement may be an appropriate physiological response to improve overall airflow. However, this glottic narrowing may cause respiratory distress of its own accord. Our observations suggest a simple approach to the diagnosis and management of patients whose respiratory distress may be caused by paradoxical vocal cord movement. Immediate relief of 'bronchospasm' in an asthmatic following tracheal intubation may establish the correct diagnosis. This has important implications for the management of these patients in the intensive care unit.

Spontaneous remission of left bundle branch block during anaesthesia.

Routine pre-operative evaluation of a 58-year-old man scheduled for repair of an inguinal hernia, disclosed a blood pressure of 200/100 mmHg. This decreased to 150/100 mmHg after a period of rest. An electrocardiogram taken as a result of this chance finding showed left bundle branch block. There were no other cardiovascular symptoms or signs. Soon after induction of general anaesthesia, the conduction defect disappeared. The return to sinus rhythm was sudden and sustained and was not related to changes in heart rate or blood pressure. One month later, his electrocardiograph remained normal.

Measurement technique and variation in intramucosal pH.

We have calculated gastric intramucosal pH (pHi) from Trip catheter saline tonometered samples in two patients undergoing ventilation using four different sampling techniques, each repeated five times. pHi was calculated from measurement of PCO2 in tonometered saline (TCO2). TCO2 was measured immediately, and then at 6-min intervals for 30 min. Variation in measurement was greatest for capped syringes stored at room temperature, and least when stored uncapped on ice. TCO2 always decreased significantly within 12 min. The mean difference in pHi (all sampling techniques) over 30 min was 0.1005 pH units. The results indicate that the calculated pHi was subject to variation as a result of both the method of sample storage and delay in measurement. An error of +/- 0.1 pH units may have clinically important implications if pHi is used to monitor either severity of illness or efficiency of resuscitation.

An assessment of the consistency of ASA physical status classification allocation.

The American Society of Anesthesiologists' (ASA) Physical Status Classification was tested for consistency of use by anaesthetists. A postal questionnaire was sent to 113 anaesthetists of varying experience working in the Northern Region of England. They were asked to allot ASA grades to 10 hypothetical patients. Ninety-seven (85.8%) responded to two mailings. In no case was there complete agreement on ASA grade, and in only one case were responses restricted to two of the five possible grades. In one case there was a significant difference in answers between anaesthetists with the FRCA (or equivalent) qualification, and those without. So much variation was observed between individual anaesthetist's assessments when describing common clinical problems that the ASA grade alone cannot be considered to satisfactorily describe the physical status of a patient.

Prediction of outcome in intensive care patients using endocrine parameters.

OBJECTIVE: To determine the ability of various endocrine parameters, measured at the time of intensive care unit (ICU) admission, to predict patient outcome. DESIGN: Prospective, cohort study of patients requiring intensive care. SETTING: The medical/surgical ICU at South Cleveland Hospital, UK and a medical/surgical ICU in a UK district hospital. PATIENTS: A total of 260 consecutive patients requiring intensive care over a 2-yr period. INTERVENTIONS: Patients were investigated within 1 hr of ICU admission by measuring plasma cortisol, serum thyroxine, triiodothyronine, and thyrotropin concentrations and by obtaining the Acute Physiology and Chronic Health Evaluation (APACHE II) score. Individual variables were compared between survivors and nonsurvivors. MEASUREMENTS AND MAIN RESULTS: There were significant differences for each endocrine parameter between survivors and nonsurvivors (all p < .01). A multiple logistic regression analysis showed that only thyroxine, thyrotropin, and cortisol concentrations were independent predictors of outcome. An equation using these variables predicted outcome with 82% accuracy at the 0.5 cutoff point of the receiver operating curve. APACHE II scores predicted outcome with 72% accuracy at the same point on the receiver operating curve. Correct prediction of death was more frequent with the Endocrine Index than with APACHE II scores. Overall predictive power of the Endocrine Index, as measured by the area under the receiver operating curve, was 0.94 (95% confidence interval 0.91 to 0.96) vs. 0.85 (95% confidence interval 0.81 to 0.89) for APACHE II scores. Combining APACHE II scores and the endocrine parameters in a single index did not improve prediction (area under receiver operating curve = 0.94). CONCLUSION: An endocrine prognostic index based on ICU admission measurements of thyroxine, thyrotropin, and cortisol concentrations is a superior discriminator of patient outcome than the APACHE II score.