Pioneering early Intensive Care Medicine by the 'Scandinavian Method' of treatment for severe acute barbiturate poisoning.

Between the 1920s and the mid-1950s, barbiturates were the sedative-hypnotic agents most used in clinical practice. Their ready availability and narrow therapeutic margin accounted for disturbingly high rates of acute poisoning, whether suicidal or accidental. Until the late 1940s, medical treatment was relatively ineffective, with mortality subsequently high - not only from the effects of coma, respiratory depression and cardiovascular shock with renal impairment, but also from complications of the heavy use in the 1930s and 1940s of analeptic stimulating agents. Incidence of barbiturate intoxication increased substantially following World War II and this paper details development of what became known as the 'Scandinavian Method' of treatment, which contributed substantially to the earliest establishment of intensive care units and to the practice and methods of intensive care medicine. Three names stand out for the pioneering of this treatment. Successively, psychiatrist, Aage Kirkegaard, for introducing effective anti-shock fluid therapy; anaesthetist, Eric Nilsson, for introducing anaesthesiologic principles, including manual intermittent positive pressure ventilation into management; and, psychiatrist, Carl Clemmesen, for introducing centralisation of seriously poisoned patients in a dedicated unit. Clemmesen's Intoxication Unit opened at the Bispebjerg Hospital, Copenhagen, on 1 October 1949. ICU pioneer Bjørn Ibsen suggested it was the initial ICU, while noting that it supplied Intensive Therapy for one type of disorder only (as had HCA Lassen's Blegdam Hospital unit for Denmark's 1952 to 1953 polio epidemic). Treatment for barbiturate poisoning during the 1950s in some other Scandinavian hospitals will also be considered briefly.

Pioneering paediatric intensive care medicine in New Zealand.

The origin of New Zealand's paediatric intensive care medicine lay in the formal establishment of Auckland Hospital's Central Respiratory Unit within the hospital's Infectious Diseases Unit (December 1958). It was initially established for the care of critically ill children, chiefly with airway and respiratory disorders or tetanus. Senior Specialist Anaesthetist Matthew Spence soon took charge, his first annual report (1960) briefly describing six children among 19 admissions and another six consulted on elsewhere. Rapid build-up of paediatric admissions-36 in 1963 becoming 104 in 1969-is detailed through Dr Spence's admirable annual reports for that period, which also provide the evidence of his organisational brilliance and personal commitment to development of the unit. Treatment for children, approximately a third of all admissions, soon included management of brain swelling from meningitis, intractable convulsions, traumatic brain injury, etc. Critically ill children were occasionally flown into Auckland; others were cared for regionally as further intensive care units developed throughout New Zealand. Successive additions to medical staffing gradually resulted in four full-time intensivists after Dr Spence's retirement in 1983. Dr James Judson computerised record-keeping from 1984 and developed a large database, containing details of children with numbers approaching 2000. At the end of 1991, the (now) Department of Critical Care Medicine completed its paediatric role over three decades, with care of children passing to a paediatric intensive care unit in the new Auckland paediatric hospital (soon to be called "Starship"). Regional intensive care units still make a substantial contribution to paediatric intensive care countrywide.

Some prehistory of New Zealand intensive care medicine.

In taking 1960 as the foundation year for the practice of intensive care medicine in New Zealand, this paper briefly looks into the previous two centuries for some interventions in life-threatening conditions. With the help of descriptions in early 19th century journals and books by perceptive observers, the author focuses on some beliefs and practices of the Maori people during pre-European and later times, as well as aspects of medical treatment in New Zealand for early settlers and their descendents. Dr Laurie Gluckman's book Tangiwai has proved a valuable resource for New Zealand's medical history prior to 1860, while the recent publication of his findings from the examination of coroners' records for Auckland, 1841 to 1864, has been helpful. Drowning is highlighted as a common cause of accidental death, and consideration is given to alcohol as a factor. Following the 1893 foundation of the New Zealand Medical Journal, a limited number of its papers which are historically relevant to today's intensive care are explored: topics include tetanus, laryngeal diphtheria, direct cardiac massage, traumatic shock, thiopentone management for fitting and the ventilatory failure due to poliomyelitis.

Further commentary on Denmark's 1952-53 poliomyelitis epidemic, especially regarding mortality; with a correction.

Berthelsen and Cronqvist recently published an article in Acta Anaesthesiologica Scandinavica including aspects which could lead on to further discussion about the Danish 1952-53 poliomyelitis epidemic. This paper considers how Bjørn Ibsen's initial approach to treatment during the epidemic was successful, as well as how it could have failed; the roles played by ventilatory failure vs. gross neurologic destruction in causing deaths; and compilations from publications of statistics concerning mortality of the epidemic. The Blegdam Hospital concept of 'life-threatening poliomyelitis' is revisited, along with its division into six anatomico-clinical categories for the 345 patients so classified. Attention is drawn to the severity of assorted cerebral lesions demonstrated in 114 of the 115 autopsies conducted from the 144 fatal cases. Despite an overall mortality rate of 41.6% among the entire epidemic's sickest patients, a lowest mortality rate of 11% in the last 18 of such patients is identified. Note is made of the difficulty in reconciling various sources for certain features -- for which the 1956 book on the epidemic, edited by H.C.A. Lassen, has been freely used. Some folklore about aspects of management is mentioned. In the light of other recent research by Dr Berthelsen an essential correction is needed in dating 'Bjørn Ibsen's Day', amending 26 August 1952 to the 27th.

Important abnormalities in recordings of somatosensory evoked potentials in coma.

We have chosen six illustrations showing how much vital information can be obtained from median nerve SEPs during the first 24 hours in coma. With avulsion of brachial plexus roots there was loss of SEPs at the cervical cord and the scalp from the affected side. In a severe injury of the cervical cord there was preservation of brachial plexus potentials, while SEPs at the cervical cord were absent. After critical deterioration in a case of repeated subarachnoidal hemorrhage, scalp SEPs with very short latency occurred, which is a finding suggestive of destruction of cortical SEP generators heralding a fatal outcome. In a case of brain injury combined with central hyperthermia, there was initially a loss of scalp SEPs probably due to the combined effect of these factors. In a case of brain injury there were bifid peaks at the scalp level. It is important to assess central sensory conduction time only to the first scalp SEP, otherwise an erroneously abnormal state may be inferred. In a patient with clinical and EEG evidence of brain death there was a loss of far-field thalamic potentials at the neck. It is important to be aware of such presentations to be able to provide corroborative assurance for the assessment of prognosis.

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.