An assessment of the tolerability of the Cook staged extubation wire in patients with known or suspected difficult airways extubated in intensive care.

The Cook staged extubation set (Cook Medical) has been developed to facilitate management of the difficult airway. A guidewire inserted before tracheal extubation provides access to the subglottic airway should re-intubation be required. This prospective cohort study examines patients' tolerance of the guidewire and its impact on clinical status around tracheal extubation in the intensive care unit. Vital signs, incidence of symptoms and patient tolerance of the wire were recorded. Twenty-three patients were enrolled and 17 (73%) tolerated the wire for 4 h. Nasendoscopy was performed in 11 of these patients and revealed one wire was in the oesophagus. The most common symptom was a mild intermittent cough in 13 patients. There was no impact of the guidewire on nursing care in 16 patients, tolerable impact in five and severe impact necessitating removal of the wire in one patient.

Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review.

Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.

Characteristics and outcomes of critically ill Aboriginal and/or Torres Strait Islander patients in North Queensland.

A retrospective cohort analysis of an admission database for the intensive care unit at The Townsville Hospital was undertaken to describe the characteristics and short-term outcomes of critically ill Aboriginal and Torres Strait Islander patients. The Townsville Hospital is the tertiary referral centre for Northern Queensland and services a region in which Aboriginal and Torres Strait Islander people constitute 9.6% of the population. Aboriginal and Torres Strait Islander patients were significantly younger and had higher rates of invasive mechanical ventilation, emergency admissions and transfers from another hospital. Despite these factors, intensive care mortality did not differ between groups (9.4% versus 7.7%, P=0.1). Higher Acute Physiology and Chronic Health Evaluation III-j scores were noted in the Aboriginal and Torres Strait Islander population requiring emergency admission (65 versus 60, P=0.022) but were lower for elective admission (38 versus 42, P <0.001). Despite higher predicted hospital mortality for Aboriginal and Torres Strait Islander patients requiring emergency admission, no significant difference was observed (20.1% versus 19.1%, P=0.656). In a severity adjusted model, Aboriginal and/or Torres Strait Islander status did not statistically significantly alter the risk of death (odds ratio 0.88, 95% confidence interval 0.65, 1.2, P=0.398). Though Aboriginal and Torres Strait Islander patients requiring intensive care differed in admission characteristics, mortality was comparable to other critically ill patients.

Toxic leukoencephalopathy in the intensive care unit.

In this article, we report two cases of acute toxic leukoencephalopathy to highlight this acute clinicoradiological syndrome as an important, although uncommon, consideration in the undifferentiated comatose patient who fails to wake following drug overdose or has unexplained neurology with a history of drug exposure. We then review the current literature and discuss potential differential diagnoses in this setting, along with proposed treatments for this condition. The cases presented demonstrate a more fulminant onset than previously well-defined acute toxic leukoencephalopathy subtypes and highlight the prognostic importance of magnetic resonance imaging in diagnosing a condition from which significant functional recovery seems possible.

Partial sequencing of Bm86 gene for studying the phylogeny of an Indian isolate of Rhipicephalus (Boophilus) microplus tick.

Tick gut glycoprotein, designated as Bm86, found on the luminal surface of the plasma membrane of gut epithelial cells of Boophilus microplus, which is a concealed antigen, has been used as vaccine candidate molecule for immunization against ticks. To better understand the molecular diversity of Bm86 gene in ticks, a portion of the cDNA was sequenced from an Indian isolate of B. microplus. Comparison of nucleotide sequence revealed that Indian isolate had 97 % homology (18 polymorphisms) with that of the Australian isolate and 96 % homology (20 polymorphisms) with that of the Cuban vaccine strain. Further, the Indian isolate differed from the Cuban vaccine isolate at 7 amino acid loci, including 5 substitutions (at residues 88, 94, 175, 176 and 177) and 2 deletions (at 183 and 184). However, protein prediction studies did not show any difference in the putative antigenic epitopes of the protein expressed.

Automated erythrocytapheresis for severe falciparum malaria.

We describe a case of severe falciparum malaria with hyperparasitaemia. Treatment with automated erythrocytapheresis, in conjunction with parenteral artesunate, produced a rapid and sustained fall in parasite burden. Several poor prognostic features were present at admission. Despite the development of a severe headache with abnormal cerebrospinal fluid parameters and transient pulmonary oedema, a complete recovery was observed. Erythrocytapheresis can be considered in selected cases where facilities exist and has theoretical and practical advantages over traditional methods of red cell exchange transfusion. The paucity of systematic or trial evidence convincingly demonstrating a benefit in terms of morbidity or mortality has limited its application. However, the lack of robust trial data should not in itself invalidate considering this therapeutic option in the appropriate context.

Difference in the level of interferon gamma mRNA transcripts on stimulation of cattle and buffalo mononuclear cells with foot and mouth disease virus-antigen: a possible role of sequence variation in promoter region.

In an attempt to resolve the claim that buffaloes differ from cattle in disease progression, this study was undertaken to compare the mitogen (conA) or antigen (foot and mouth disease virus) induced expression levels of interferon gamma (IFN-γ mRNA in peripheral blood mononuclear cells (PBMCs) by real-time quantitative PCR. In general, the levels of IFN-γ mRNA were lower in buffaloes than in crossbred cattle. Significantly higher levels of IFN-γ mRNA were also observed in crossbred cattle when induced with FMD virus (1 µg). Analysis of the partial promoter sequences of the IFN-γ gene from the respective species revealed a conserved 4 base (GTCT) deletion in all the buffalo promoter sequences. In-silico analysis indicated the binding of glucocorticoid receptor (GR) and erythroid nuclear factor (NF-E) to this region in cattle. GR has been shown to be a transcription factor by itself and also regulates other major transcription factors like NF-κB and AP-1. The differential expression levels of IFN-γ mRNA between these species could be due to this deletion in the promoter region of buffalo. Further studies involving mobility shift and promoter assays would throw more light on the differential expression levels.

Acquired hypernatraemia is an independent predictor of mortality in critically ill patients.

This study reports the incidence and associated mortality of acquired hypernatraemia (Na > 150 mmol x l(-1)) in a general medical/surgical intensive care unit. Patients admitted over a 5-year period with normal sodium values were eligible for inclusion; exclusions were made for burn/neurosurgical diagnoses and for hypertonic saline therapy. From 3475 admissions (3317 patients), 266 (7.7%) episodes of hypernatraemia were observed. Hospital mortality was 33.5% in the hypernatraemic group and 7.7% in the normonatraemic group (p < 0.001). Acquired hypernatraemia was an independent risk factor for in-hospital mortality (OR 1.97, 95% CI 1.37-2.82, p < 0.001). Intermediate sodium levels (145-150 mmol x l(-1)) were associated with increased mortality (OR 1.42, 95% CI 1.02-1.98). Uncorrected sodium at discharge (p = 0.001) and peak sodium (p = 0.001) were better predictors of mortality than time to onset (p = 0.71) and duration of hypernatraemia (p = 1.0). Hypernatraemia avoidance is justified, but determinants of hypernatraemia and benefits of targeted treatment strategies require further elucidation.

Airway obstruction due to a pre-vertebral haematoma following difficult central line insertion--implications for ultrasound guidance and review of the literature.

We describe a case of airway obstruction secondary to a large pre-vertebral cervico-mediastinal haematoma following failed attempts at insertion of an internal jugular central venous line. The need for a high index of suspicion to diagnose this injury and early aggressive intervention to manage it are outlined. The role of ultrasound guidance in preventing such a complication is reviewed, as well as other possible mechanisms of haematoma development.

The entrapped central venous catheter.

The central venous catheter (CVC) is associated with numerous complications more so during the process of insertion. We report for the first time how an indwelling catheter was entrapped by a replacement catheter on the same side, after being speared by the introducer needle and guidewire. The diagnosis was made when there was difficulty in removing the old catheter. Subsequently, interventional radiology services were used to define the problem and help in removal of the entrapped catheter. The mechanism of entrapment and the actual procedure used for removal of the catheter is described. The dangers of insertion of a CVC on the same side as a pre-existing one are highlighted.

Pathotyping of Newcastle disease virus isolates from pet birds.

Four Newcastle disease virus (NDV) isolates obtained from a pigeon, lory, parrot, and love bird were subjected to biological and molecular characterization. All the isolates were identified as velogenic with intracerebral pathogenicity indices (ICPI) of 1.9-2.0. All the isolates had a 112RRQKRF117 motif in the fusion protein cleavage site (FPCS), typical for pathogenic NDV. Phylogenetic analysis placed the isolates along with a velogenic Indian isolate of Cl group recovered during 1987.

Life-threatening airway obstruction caused by a retropharyngeal haematoma.

We present the case of a 68-year-old woman who had a large cervicomediastinal haematoma that caused life-threatening airway obstruction. Retropharyngeal haematoma may occur in any age group and following a variety of causes. Retropharyngeal haematomas must be considered as a cause of airway obstruction following common injuries such as blunt cervical trauma or internal jugular vein cannulation. A high index of suspicion and early lateral neck X-ray is essential for safe management of this rare but potentially life-threatening injury.