Fluid resuscitation in critically ill patients-timing and dose matters.

Fluid management is a complex subject in healthcare, particularly when pertaining to critically ill patients. Following a literature search on international recommendations regarding fluid administration for shocked patients, an audit was undertaken at Rotorua Public Hospital, New Zealand, to assess how the local fluid resuscitation strategy could be improved. The first part of the audit looked at the fluid resuscitation approach used to treat shocked patients admitted to the ICU of Rotorua Hospital in 2014 and changes required to achieve best practice recommendations. The second part tested the success and impact of the subsequently implemented, more measured approach to fluid resuscitation in 2016. Data was extracted from patient files, fluid charts and electronic records to assess fluid administration and de-escalation measures. The collated information was analysed and compared to recommendations found in the literature. The complete audit cycle revealed not only a significant improvement in adherence to best practice guidelines, but also an association with better patient outcomes.

Remifentanil patient-controlled analgesia for labour: a complete audit cycle.

Remifentanil patient-controlled analgesia (PCA) was introduced to a small maternity unit where an extensive epidural service was difficult to provide. This was a new service and the New Zealand College of Midwives had serious doubts about the efficacy and safety of remifentanil, so auditing its use was important. In a two-stage audit, clinical notes of 244 consecutive remifentanil users were studied between January 2008 and November 2009. We developed a questionnaire to assess the parturients' satisfaction with remifentanil PCA and designed a proforma to evaluate it against four standards of best practice. During the two audit periods, timely commencement of PCA was achieved in 65% and 82% of cases, respectively. A 70% compliance rate with monitoring standards fell to 10% after the withdrawal of supervision by an acute pain team, but improved to 91% following implementation of regular midwifery training sessions and a redesigned partogram and prescription flowchart. Ninety-four percent of women rated remifentanil PCA as excellent, very good or good. Maternal side-effects were nausea, pruritus and drowsiness. A comparison of Apgar scores of consecutive neonates born by normal vaginal delivery to women receiving no analgesia, with those born to women using remifentanil PCA, demonstrated no difference. As a result of our audit, remifentanil PCA is now viewed by our midwives as an effective and safe method when accompanied by 1:1 care and appropriate monitoring. With our input other maternity units have introduced it, especially where epidural service provision is limited, and for patients in whom epidural analgesia is contraindicated.

Bonfils semirigid endoscope for guidance during percutaneous tracheostomy.

We report on the use of the Bonfils semirigid scope for endoscopic guidance during percutaneous dilational tracheostomy. Forty patients requiring percutaneous dilational tracheostomy on the General or Neurosurgical Intensive Care Unit were enrolled in this study. We used the '45 degree curved distal tip' scope in the first 15 patients, evaluating its ease of use, optical quality of focus and image resolution as well as light intensity on a 10-point scale. We evaluated straight and curved versions of it in another 15 and 10 patients, respectively. We examined the impact on ventilation and cardiovascular parameters. In all patients (n = 40) visualisation of the procedure was satisfactory. There were no clinically significant changes in ventilatory or cardiovascular parameters. The image quality for most patients received a score of 7-10. The Bonfils scope provides a practical alternative to flexible bronchoscopes in this setting.