Delayed therapeutic hypothermia following cardiac arrest secondary to chloroquine toxicity.

We describe a case of severe chloroquine intoxication resulting in a cardiac arrest requiring prolonged cardiopulmonary resuscitation. An excellent neurological outcome was achieved because the cardiac arrest occurred in a young patient lacking comorbidities in an environment where advanced life support was provided rapidly and effectively. Therapeutic hypothermia was instigated once profound shock and arrhythmias had resolved, and this may have contributed to her recovery. If a patient's immediate clinical condition post-cardiac arrest precludes therapeutic hypothermia, the use of this therapy should be reconsidered as their condition changes.

Introducing intensive insulin therapy: the nursing perspective.

Intensive insulin therapy (IIT) for the management of high blood glucose can reduce mortality and morbidity in the critically ill. However, there is little published literature on how to implement it successfully. The aim of this study is to chronicle the development and difficulties encountered in implementing an IIT protocol in a critical care unit in a district general hospital. A nurse-led protocol was developed. Qualitative audit was undertaken during development and implementation to identify potential problems with using the Bath Insulin Protocol. Regular feedback sessions were introduced to encourage change and further identify problem issues. Qualitative audit led to changes in practice for individual nurses and changes to other unit protocols. The main change for individual nurses was to measure blood glucose hourly using a bedside glucometer. The unit's feeding and drug dilution policies were identified as a potential cause of glucose instability and were modified. To implement IIT successfully, it is necessary to consider changing working practices and to identify other unit protocols which can cause glucose instability. The additional nursing workload must be considered and appropriate means of supporting staff identified.

Does hyperglycaemia precede the clinical onset of myocardial ischaemia?

Stress hyperglycaemia has been observed previously in a large proportion of patients with acute myocardial infarction. We report a patient who presented to our intensive care unit (ICU) on two occasions with acute hyperglycaemia preceding new onset myocardial ischaemia by several hours.

Use of the ProSeal Laryngeal Mask Airway to initiate ventilation during intensive care and subsequent percutaneous tracheostomy.

The ProSeal Laryngeal Mask Airway is a supraglottic airway that aims to provide improved airway seal and separation of the gastrointestinal and respiratory tracts. We report two cases in which the ProSeal Laryngeal Mask Airway was used to initiate controlled ventilation in the intensive care unit and subsequently provide airway maintenance during percutaneous dilational tracheostomy. The first case involved a patient with a known difficult airway who had previously been impossible to intubate conventionally. In both cases, airway management and subsequent tracheostomy were performed without complication.

Use of the Pro-Seal LMA facilitates percutaneous dilatational tracheostomy.

PURPOSE: To study the feasibility of using the Pro-Seal laryngeal mask airway (LMA) for airway maintenance during bronchoscopic guided percutaneous tracheostomy. METHODS: Observational study of 23 patients in an 11-bed general intensive care unit. The patient's tracheal tube was exchanged for a Pro-Seal LMA before undertaking percutaneous tracheostomy. RESULTS: Inspiratory pressure and tidal volumes achieved during the procedure were recorded. The median peak inspiratory pressure was 25 (standard deviation 4.2) cm H(2)O. There was no loss of tidal volume in 11 patients, a loss of less than 100 mL x breath(-1) in 11, and loss of more than 100 mL in one. A Pro-Seal LMA successfully maintained the airway and allowed adequate ventilation during percutaneous tracheostomy in all 23 patients. In all patients bronchoscopy through the Pro-Seal LMA provided a clear view of the cords and trachea and there was no laryngeal or tracheal soiling at any stage of the procedure. CONCLUSION: The Pro-Seal LMA provides a reliable airway and allows effective ventilation during percutaneous tracheostomy. The passage of a fibrescope through the Pro-Seal LMA and glottis is easy and provides a clear view of the upper trachea.