Is early enteral feeding safe in patients who have suffered spinal cord injury?

OBJECTIVE: To examine whether enteral feeding is a safe technique to use in the acute stage of spinal cord injury. METHODS: We searched the departmental computerised patient database and clinical records for all patients with spinal cord injuries admitted to the Auckland Hospital Intensive Care Unit (ICU), known as the Department of Critical Care Medicine (DCCM), between January 1988 and December 2000. Patients were included in the study if they had suffered complete spinal cord transection resulting in either paraplegia or quadriplegia. Data was collected for the following variables: length of time to commence enteral feeding, type of enteral feeding, duration of enteral feeding and reasons for interrupting the feed. RESULTS: Thirty-three patients were found and were included in the study. Twenty-seven (82%) of the patients commenced enteral feeding in the DCCM, 25 by nasogastric (NG) and 2 by nasojejunal (NJ) tube. Feeding was commenced a median of 2 days after admission and the median length of enteral feeding was 7.7 days. The main feeding complications that resulted in interrupting the feed were high gastric aspirates. One patient commenced on enteral feeding developed medical complications that prevented continuation. Two patients on NG feeding converted to NJ feeding. CONCLUSION: No major complications associated with enteral feeding were seen in this study. This would indicate that enteral feeding can be safely administered in the acute stage of spinal cord injury provided complications are monitored for daily.

A decade of intensive care unit trauma admissions in Auckland.

AIMS: To describe the demographics, nature and severity of injury of trauma admissions to a New Zealand urban Intensive Care Unit (ICU) over a ten year period; to determine differences in injury characteristics between patients received from inside and outside the local trauma catchment area; and to calculate incidence rates in the local population served, to identify high risk groups of patients. METHODS: We carried out a cross-sectional analysis of a prospective ICU patient registry. Data on all trauma admissions from 1988 to 1997 to the ICU of a large New Zealand urban hospital were studied with respect to age, gender, ethnicity, injury type and severity, and referral status. National Census data for the ICU catchment area were used to calculate incidence rates for local admissions. RESULTS: A total of 2305 trauma patients were admitted over the period of the study, accounting for 25% of all ICU admissions. The median age was 28 years and 75% were males. Blunt trauma, mostly due to motor vehicle crashes, accounted for 95% of admissions and penetrating trauma was very rare. The median Injury Severity Score (ISS) was 26 and most life threatening injuries occurred in the head region. Referred admissions were more severely injured and had a higher prevalence of severe head injury than local admissions. The ICU trauma admission rate for local patients was 34.6 per 100,000 person-years. Males had a higher rate than females in all age groups. New Zealand Europeans made up the majority of admissions, but Maori and Pacific Island males had the highest incidence rates. CONCLUSIONS: This study identified trauma as a major component of the ICU population. ICU trauma admissions were characterised by young males with head injuries resulting from motor vehicle crashes. Referred admissions were more severely injured than local admissions and would thus distort the estimated incidence of trauma in the local geographic region served. Calculation of incidence rates highlighted a significantly higher risk of ICU trauma admission amongst Maori and Pacific Islands people than New Zealand Europeans.

Elderly trauma patients admitted to the intensive care unit are different from the younger population.

AIMS: This study was undertaken to investigate the demographic profile of elderly (65 years old and over) patients with severe trauma admitted to the Intensive Care Unit of Auckland Hospital and to compare their characteristics with those of the younger (under 65 years) trauma patients. A further aim was to see if specific areas of potential injury prevention could be identified. METHOD: Data analysis covering ten years, from January 1987 to December 1996, on data extracted from the existing database at the Intensive Care Unit of Auckland Hospital. RESULTS: The elderly comprised 8.7% (183 of 2092) of the trauma admissions during the study period. The elderly, when compared with the younger group, were significantly more likely to be female, New Zealand European and admitted as a result of a fall. They were significantly less likely to be drivers in a road traffic crash or, if a driver, to have a blood alcohol above the legal limit. Mortality in the older group (27.8%) was significantly higher, though median injury severity score (25) and length of stay (57.9 hours) were similar. CONCLUSIONS: Elderly trauma patients in the Intensive Care Unit are a group with distinctive demographics, mechanisms of injury, injury types and outcomes. This information needs to be considered for the future planning of trauma and prevention services in New Zealand.

Cost containment: the Pacific. New Zealand.

New Zealand is a small nation with an extensive state-funded system of health, education, and welfare that is currently under "reform." The healthcare system remains largely government-funded and is free to all New Zealand residents. Healthcare spending accounts for approximately 7.4% of the country's gross domestic product and has not changed in the last 5 yrs. Ninety-three percent of New Zealand's ICUs are in public hospitals, where ICU beds constitute 0.9% of the total number of beds. In all, there are 43 ICU beds/1 million inhabitants. Between 1989 and 1992, the number of public hospital beds decreased by 19% and the number of ICU beds decreased by 5%. ICU Resources have been limited for many years, and clinicians have responded by attempting to prevent disease and limit its severity, by vetting (and declining) requests for ICU admission, by reducing length of ICU stay of both survivors and nonsurvivors, and by reducing marginal costs. Both limiting and actively withdrawing therapy are well established practices in New Zealand ICUs. The country's physicians are conservative in their use of new technology but demand excellence and value in equipment. ICU technology and knowledge diffuse easily throughout New Zealand because of the country's geography and population distribution, in addition to the activities of the Australian and New Zealand Intensive Care Society (ANZICS) and the defined specialty training pathways for intensive care. Hospital care is relatively cheap and nurse extenders, respiratory therapists, and ward pharmacists are not used. Flow charts in the ICU are custom-designed and not computerized, but computers are increasingly being used for clinical databases and ICU policy development.

Grading asthma severity: using the APS component of the Apache II system.

OBJECTIVE: Measurement of severity is fundamental to the description and comparison of case series, treatment regimens and disease outcomes. This study examines the Acute Physiology Score (APS) as a severity measure of an acute "life-threatening" asthma attack. DESIGN: The APS in the emergency department (ED) and ICU, demographic, treatment and outcome variables were prospectively studied. Relationships between severity, treatment and progress were investigated. In addition, patients were stratified according to ED APS and differences between the participating hospitals were examined. SETTING: Emergency Departments and Intensive Care Units of two New Zealand hospitals. PATIENTS: 64 admissions to the ICUs following an acute episode of asthma. INTERVENTIONS: Standard management of acute asthma as practised at the two participating hospitals. MEASUREMENTS AND RESULTS: Both the treatment delivered (intravenous salbutamol, sodium bicarbonate and IPPV) and the rate of improvement as defined by change in APS between the ED and the ICU were found to be strongly related to ED APS. Similarly, the length of stay in the ICU correlated with the ICU APS. Stratification on the basis of ED APS allowed small but significant differences in patient physiologic derangement, dose of salbutamol, use of IPPV and incidence of complications to be detected between patients at the two hospitals. CONCLUSION: This prospective study involving two hospitals validates the APS as a method for measuring the severity of an acute asthma attack. It demonstrates how correction for severity can be used to compare treatment and outcome variables in different case series.

A comparison between electroencephalography and somatosensory evoked potentials for outcome prediction following severe head injury.

The value of somatosensory evoked potentials (SEPs) for the prediction of outcome following severe head injury (HI) is established. The role of the electroencephalogram (EEG) in this setting is uncertain. In this comparative study, SEPs and EEGs were recorded within 3 days of severe HI in 90 patients, and the results related to outcome at 6 months. Patients with an isoelectric EEG or an EEG with repeated isoelectric intervals died. Reactivity of the EEG to external stimulation tended to be associated with favorable outcome. Grading of the EEGs on the basis of frequency composition otherwise provided no prognostic information. The presence of SEP scalp potentials bilaterally predicted favorable outcome, particularly if the central conduction times were normal. Conversely, the absence of one of both scalp potentials was associated with unfavorable outcome. EEGs thus provided useful prognostic information in only a minority of patients. By comparison, SEPs allowed prediction of both favorable and unfavorable outcomes in a much larger number of patients, and were therefore prognostically superior.

Early prediction of outcome from cerebral trauma by somatosensory evoked potentials.

The prognostic value of short-latency somatosensory evoked potentials (SEP) during the first 4 days after severe head injury was studied in a group of 100 ICU patients. There was a strong association between the presence of bilateral cortical potentials and a good recovery or moderate disability 6 months after injury. In contrast, the bilateral or unilateral absence of cortical potential was associated with severe disability, persistent vegetative state, or death in a high percentage of patients. A reliable prediction of outcomes was obtained from SEP recorded within 24 h of head injury. Predictive accuracy was not influenced by the time of recording or cumulative analysis of consecutive daily SEP over the first 4 days after injury. Short-latency SEP can provide a reliable and accurate prognosis for sedated and curarized patients, and can have an important role in the management and triage of patients with severe head injury who are undergoing intensive therapy.

A comparison of AIS-85 with AIS-80 for injury scaling in blunt trauma.

As the effects on injury scaling of the differences between the 1980 and 1985 revisions of the AIS are unknown in blunt trauma, we compared them in all 1270 critically injured (median ISS, 26) blunt trauma patients (75% male, 74% road crash, overall mortality 17%) admitted to the Department of Critical Care Medicine at Auckland Hospital from 1983 through 1987. In 911 patients (72%) there were no differences between AIS-80 and AIS-85 in any body region or in derived ISS. Changes in AIS grades were most common in the abdomen (205 patients), thorax (100 patients), and head (61 patients) regions. Median ISS overall for the 1270 patients was unchanged at 26. One percent of patients had changes in ISS of 16-24 points. Direct comparison of groups of patients scored with these two revisions of the AIS is inappropriate, particularly in those with abdomen region injury.

Injury in Auckland, New Zealand: an unexplored epidemic.

The applicability of regionalization of injury care in New Zealand has not yet been investigated. In a first attempt to define the extent of the problem, all injured patients presenting to the resuscitation room in the emergency department of a large teaching hospital over a 1-year period were studied. Data on mechanism of injury, injury severity, resource utilization, management and outcome were recorded. A total of 602 patients was evaluated. Of these 37 per cent had Injury Severity Scores greater than or equal to 16 and 24 per cent were admitted to intensive care. Overall mortality was 10 per cent with the mean ISS for CNS related deaths being 39; for non-CNS related deaths, 46. The study confirmed that the characteristics of nonpenetrating injury in New Zealand were similar to the USA. Extrapolating from US data, one could anticipate that up to 30 per cent of deaths following injury in NZ annually may be preventable. If regionalization could reduce this rate to just 10 per cent, 360 lives could be saved annually with a contribution of $8 million to the GNP and $2.2 million to the annual government tax accounts.

Patient selection for intensive care: a comparison of New Zealand and United States hospitals.

To examine how the use of intensive care varies, we compared 5,030 adult ICU admissions in 13 U.S. hospitals with 1,005 patients in two New Zealand (N.Z.) hospitals. Despite similar national demographic and hospital patient characteristics, there were substantial differences in the use of intensive care. The N.Z. hospitals designated 1.7% of their total beds for intensive care compared to 5.6% in the U.S. hospitals. The average age for N.Z. admissions was 42 compared to 55 in the U.S. (p less than .0001). The N.Z. ICUs admitted fewer patients with severe chronic failing health (N.Z. 8.7%, U.S. 18%) and following elective surgery (N.Z. 8%, U.S. 40%). Approximately half the N.Z. admissions were for trauma, drug overdose, and asthma while these diagnoses accounted for 11% of U.S. admissions. When controlled for differences in case mix and severity of illness, hospital mortality rates in N.Z. were comparable to the U.S. This study demonstrates substantial differences in patient selection among these U.S. and N.Z. ICUs that have equal technical and manpower capabilities and provide similar high-quality intensive care. Physicians from both countries justify the differences on medical criteria; however, both approaches to patient selection cannot be optimal. Additional outcome comparisons between acutely ill patients treated in the U.S. and N.Z. could help refine ICU selection criteria and improve the precision of clinical decision-making.

Trauma in Auckland: an overview.

Data are presented on all 569 subjects who, as a result of trauma, either died or were admitted to hospital in Auckland over a four week period. Median age was 23 with an overall 3:2 male:female ratio. Median injury severity score (ISS) was five with 9% of subjects having an ISS of 16 or more (major trauma). Blunt trauma accounted for 84% of all injuries. Life threatening injuries were most commonly to the head, thorax and abdomen while the largest number of less severe injuries were to the extremities. Eight subjects died before admission to hospital and a further six in hospital. Definitive care was given to 98% of patients at Middlemore and Auckland hospitals (including the onsite Princess Mary paediatric facility) but 26% had presented first to other hospitals and 43% of all patients were transferred from one hospital to another. The 561 patients used 6380 hospital days (including 314 intensive care days) and the following services--operating room 63%, orthopaedic ward 45%, plastic surgical ward 17%, paediatric ward 15%, neurosurgical ward 10%, general surgical ward 5%, intensive care 5% and CT scanner 4%. Only one hospital death was judged potentially preventable. This study reveals areas where trauma care could be improved, demonstrates the large amount of hospital resources required to treat trauma and particularly highlights the urgent need for studies into strategies for trauma prevention in New Zealand.

Deaths from trauma in Auckland: a one year study.

We report a one year prospective study of all deaths from trauma in the Auckland region. Data was collected on the circumstances of death from coroner's, police and hospital records. All cases had autopsies and the injuries were scored using the abbreviated injury scale (AIS) system. The group of 236 had a median age of 27 years and 73% were under the age of 45. Seventy-two percent were male. Blunt trauma, predominantly the result of road crashes, accounted for 89% of the fatalities. Most deaths occurred at the site of injury and only 37% survived to reach hospital. Cases were audited if death occurred without a critical or unsurvivable injury. Thirteen cases were considered to be potentially salvageable if medical treatment had been optimal. The implications for the organisation of prehospital and inhospital trauma care are discussed.

The assessment of severe head injury by short-latency somatosensory and brain-stem auditory evoked potentials.

The relative prognostic value of short-latency somatosensory evoked potentials (SEPs) and brain-stem auditory evoked potentials (BAEPs) was assessed in 35 patients with post-traumatic coma. Analysis of the evoked potentials was restricted to those recorded within the first 4 days following head injury. Abnormal SEPs were defined as an increase in central somatosensory conduction time or an absence of the initial cortical potential following stimulation of either median nerve. Abnormal BAEPs were classified as an increase in the wave I-V interval or the loss of any or all of its 3 most stable components (waves I, III and V) following stimulation of either ear. SEPs reliably predicted both good and bad outcomes. All 17 patients in whom SEPs were graded as normal had a favourable outcome and 15 of 18 patients in whom SEPs were abnormal had an unfavourable outcome. Although abnormal BAEPs were associated with an unfavourable outcome in almost all patients (6 of 7), only 19 of 28 patients with normal BAEPs had a favourable outcome. The finding of normal BAEPs was therefore of little prognostic significance. These results confirm the superiority and greater sensitivity of the SEP in detecting abnormalities of brain function shortly after severe head trauma.

Warm peritoneal dialysis in the management of accidental hypothermia: report of five cases.

Five patients with accidental hypothermia are reported. Admission rectal temperatures ranged from 24 degrees C to 31.7 degrees C and two patients had suffered circulatory arrest. Ages ranged between 25 and 77 and predisposing factors included alcoholism, gluterthimide poisoning, pancreatitis and cerebro-vascular accident. Along with respiratory and circulatory management in an intensive care unit the patients were actively rewarmed by peritoneal dialysis with fluid at 37 degrees C. Rewarming was rapid, smooth and free of complications. All five patients made a good recovery.