Rational Clinical Pathology Assessment in the Intensive Care Unit.

Blood tests are ordered on a daily basis in intensive care units (ICU). There are no widely accepted guidelines for testing requirements. This study investigated the impact on ICU laboratory test costs of a multi-strategy change in practice involving routine blood testing. A single centre, prospective, interventional study using historical controls was undertaken to investigate the impact of ICU specialist authorisation of high-volume routine tests on ICU laboratory test costs. Prior to commencement of the study, ICU nursing and junior ICU doctors were able to order tests. During the six-month intervention period, the ICU specialists authorised routine blood tests. Adverse events related to not performing blood tests were also recorded. Overall ICU laboratory test costs decreased by 12.3% over the six months (P=0.0022 versus historical control) with a mean compliance of 51% with the test authorisation protocol. The costs of frequently ordered tests (classified as high-volume) decreased by 20% (P=0.0022 versus historical control). These accounted for an average of 54 ± 3% of the overall ICU blood test costs (blood gas analyses 17%, simple chemistry tests consisting of electrolytes, liver function, calcium, phosphate, magnesium 14%, coagulation 12% and full blood count 11%). Two protocol-related adverse events were recorded and judged as minor and were resolved by ordering tests during the day. No adverse patient outcomes resulted from these two events. Blood testing authorisation by an ICU specialist was associated with significant cost savings in ICU and no adverse patient outcomes.

Activated protein C in toxic shock syndrome: a case report.

The mortality from septic shock remains high despite the availability of modern critical care facilities. In recent years, new agents have been tested to reduce morbidity and mortality in patients with severe sepsis. Among them, recombinant human activated protein C (rhAPC) has been reported to significantly reduce mortality and morbidity in patients with severe sepsis and one or more acute organ failures. We describe our experience with this drug in the early reversal of septic shock from toxic shock syndrome.

An intermittent foreign body in the airway: a case report.

A case is described of a surgical 'stay' suture which apparently disappeared from the tracheostomy site and took an unusual course before it reappeared in the patient's tracheostomy tube. Our report highlights the importance of documentation of the surgical techniques and procedures used in the performance of a tracheostomy and the importance of daily bedside examinations in the critically ill patient.

Conservative management of a posterior tracheal tear: a case report.

We describe a case of posterior tracheal wall tear managed conservatively with a successful outcome. The presentation of a sudden increase in cuff volume and subcutaneous emphysema presents a challenging management problem requiring careful bronchoscopic and computed tomography delineation and isolation of the injury using a double lumen tube. This case also highlights the vulnerability of the trachea to injury from airway intervention and considers the possible mechanisms of tracheal injuries during the commonly performed intensive care procedure of percutaneous tracheostomy.