Eye care for the critically ill

Purpose: To evaluate the effectiveness and efficiency of an algorithm in the prevention of ocular surface disease in sedated and unconscious patients in the intensive care unit (ICU).¶Methods: The eyes of all sedated and unconscious patients admitted to an ICU between September and December 1998 were managed according to an eye care algorithm. The applications of the preventive measures were assessed by a single observer twice weekly. The lid position, the presence and degree of keratopathy, sedation score, and the treatment received were documented at every assessment.¶Results: Thirty-four patients were recruited for management according to the eye care algorithm over a period ranging from 1 to 28 days. Four patients were excluded because of failure by staff to adhere to the protocol. In 18 patients no active treatment was required. Out of six patients who had conjunctival exposure and were given ocular lubricants, four maintained clear corneas. No corneal or conjunctival staining was noted in two of the four patients whose lids required closure with Micropore tape for corneal exposure. Use of lid taping and lubricants prevented corneal abrasion in two patients who were prone ventilated. The prevalence of ocular surface abnormalities was 8.7 % where the algorithm was properly followed (23 patients).¶Conclusion: The proposed eye care algorithm appears to be effective in preventing ocular surface abnormalities in the sedated and unconscious patients in the ICU, and efficient in that it may reduce the workload required for critically ill patients.     

TISS and mortality after discharge from intensive care

Objective: To examine the effect of high levels of pre-intensive care unit (ICU) discharge care, as assessed by the Therapeutic Intervention Scoring System (TISS), on subsequent hospital mortality.¶Design: A 1-year prospective, observational study.¶Setting: The ICU and wards of a university teaching hospital with no high dependency facility (HDU).¶Patients: A total of 283 patients were discharged to hospital wards between July 1997 and June 1998.¶Results: 11 % of all ICU discharges subsequently died in hospital. Patients discharged with a TISS of 20 or greater had a 21.4 % mortality compared to 3.7 % for those with a TISS of less than 10. Increasing age, Acute Physiology Score (APS) on admission and male sex were also significantly associated with post-discharge death.¶Conclusions: In a hospital without HDU facilities, patients who are receiving HDU levels of care on discharge from the ICU have a high in-hospital mortality.     

Non-invasive ventilatory approach to treatment of acute respiratory failure in neuromuscular disorders. A comparison with endotracheal intubation

Objective: Prospectively to investigate the efficacy of non-invasive positive pressure ventilation (NPPV) combined with cricothyroid “mini-tracheostomy” (CM) as a first-line intervention in patients with acute respiratory failure (ARF) of neuromuscular origin, in comparison with positive pressure ventilation (PPV) via endotracheal intubation (ETI).¶Design: Prospective analysis of the short-term outcomes of 14 non-consecutive patients suffering from ARF of neuromuscular origin who were administered NPPV and comparison with the outcomes of 14 matched historical control patients receiving conventional mechanical ventilation (MV) via ETI.¶Setting: Adult five-bedded respiratory intensive care unit in a university hospital.¶Patients and interventions: Fourteen neuromyopathic patients who developed hypercapnic ARF and were submitted to NPPV (group A) and fourteen matched historical control patients, who were administered PPV via ETI (group B). Seven subjects receiving NPPV also underwent CM.¶Outcome measures: Mortality during ICU stay and treatment failure were evaluated; treatment failure was defined as death or the need for ETI for the NPPV group and as death or the inability to wean from MV for the control group. Length of stay in the ICU and time to improvement, defined as the time required for a significant relief of dyspnea and neurologic impairment and for correction of arterial blood gases, were also compared.¶Results: Intra-hospital mortality and treatment failure were lower in the NPPV group than in the conventional PPV via ETI group (2 vs 8 cases and 4 vs 11 cases, respectively). In addition, the duration of ICU stay for subjects who underwent NPPV was shorter than for patients who were intubated (13.6 ± 9.7 vs 47.1 ± 51.9 days). “Mini-tracheostomy” was well tolerated and no significant side effects were encountered. Two patient were excluded from the study because they showed a severe inability to swallow and needed to be intubated to protect the upper airway from the risk of aspiration.¶Conclusions: Non-invasive positive pressure ventilation in combination with CM may be considered as a safer and more effective alternative to ETI in the treatment of patients with neuromuscular disorders (NMD) who develop ARF and require MV; nevertheless, patient selection remains important, since a significant proportion of neuromyopathic patients might have to be excluded from NPPV because of severe risk of aspiration.     

Acute neuromuscular respiratory failure after ICU discharge

Objective: To describe a syndrome of acute neuromuscular respiratory failure (NM-ARF) caused by ICU-acquired acute myopathy and neuropathy.¶Design: Case series.¶Setting: General Regional University Hospital in Brescia, Italy.¶Patients: Five adult patients with NM-ARF after prolonged ICU stay and successful weaning from the ventilator and ICU discharge.¶Interventions: None.¶Measurements: Clinical signs of NM-ARF, electroneurography and electromyography (ENMG) of peripheral nerves and muscles, and functional assessment of respiratory muscles.¶Results: NM-ARF was diagnosed at the time of (one case), or 1–3 days after, ICU discharge. Limb weakness alarmed the physicians, while the signs of the NM-ARF were initially undetected. In the first observed case the acute respiratory failure was near fatal, and necessitated ICU readmission, while in the other cases 2 weeks of aggressive chest physiotherapy permitted resolution of the respiratory failure. History, clinical course and ENMG indicated the diagnosis of critical illness myopathy and neuropathy (CRIMYNE). Three patients recovered fully, while two had persisting evidence of axonal polyneuropathy several months after the onset.¶Conclusions: Critically ill patients with prolonged ICU stay, sepsis and MOF are at great risk of developing CRIMYNE, which in turn may be responsible for NM-ARF. This latter complication may arise after resolution of the respiratory and cardiac dysfunctions and successful weaning from the ventilator. As NM-ARF may cause unplanned ICU readmission or even unexpected death, strict clinical surveillance and monitoring of respiratory muscle function is recommended after discharge to the general ward of patients with proven NM-ARF. Early intensive chest physiotherapy can resolve the condition.     

Septic shock without documented infection: an uncommon entity with a high mortality

Objectives: To determine whether patients with clinically identified infection have the same outcome as patients with apparent sepsis but no identified infectious source.¶Design: Retrospective analysis of patient data.¶Patients: All patients treated with septic shock in a 31-bed intensive care unit (ICU) over a 3-year period.¶Results: Data from 227 patients were analysed. Eighty-seven percent had a clinically identified source of infection. ICU mortality was higher in septic shock patients without a clinically identified source of infection than in those with an identified source of infection (86 % versus 66 %, p < 0.05).¶Conclusions: A small number of patients presenting with septic shock have no clinically identified infection. These patients have a higher mortality rate than patients in whom an infection is identified.     

Nosocomial sinusitis with isolation of anaerobic bacteria in ICU patients

Objective: To determine the frequency and the eventual clinical characteristics of nosocomial sinusitis with anaerobic bacteria isolation in patients in the intensive care unit (ICU).¶Design: Retrospective study.¶Setting: A 12-bed medical ICU in a teaching hospital.¶Patients: 30 adult patients with documented nosocomial maxillary sinusitis.¶Interventions: None.¶Measurements and results: Using appropriate microbiological techniques, 33 anaerobic bacterial strains were isolated in 18/30 patients (60 %) with nosocomial sinusitis. Anaerobic bacteria were associated with aerobic strains in 13 patients (72 %), whereas in 5 patients (28 %) only anaerobic strains were isolated in sinus puncture cultures. The most frequently isolated species were Prevotella sp. (n = 20, 60 %) and Fusobacterium nucleatum (n = 5, 15 %). The production of β -lactamase was demonstrated in 13/27 gram-negative anaerobic bacteria. All patients in whom anaerobic bacteria were isolated from transnasal punctures had had a nasogastric tube. Patients in whom anaerobic bacteria were isolated more frequently had neurological disorders upon admission (p < 0.02). Ten patients (30 %) had nosocomial pneumonia, 8 of whom had at least one identical strain in both lung and sinus cultures, including 2 patients with anaerobic bacteria isolation.¶Conclusions: Using appropriate microbiological techniques, anaerobic bacteria were frequently isolated in nosocomial sinusitis. If necessary, the empirical choice of antimicrobial therapy in patients with nosocomial sinusitis should take into account these results.     

Lack of significant treatment effect of plasma exchange in the treatment of drug-induced toxic epidermal necrolysis?

Objective: Comparison of outcome in patients with toxic epidermal necrolysis (TEN) in patients who received plasma exchange (PE) compared with the results in two other centres that used almost identical treatment protocols but without PE.¶Design: Retrospective comparative case series with two recently published case series serving as controls.¶Setting: National burns intensive care unit (ICU) and Department of Transfusion Medicine at Linköping University Hospital, Sweden.¶Patients: 8 consecutive patients admitted with TEN who received PE during 1987–1997.¶Interventions: Neither prophylactic antibiotics nor cortisone were used. The patients were given a median of 5.5 PE treatments (range 1–8).¶Results: Eight patients with a median (range) age of 45 years (5–89) and with a median skin involvement total body surface area (TBSA) of 38 % (12–100) were treated. The length of stay in the burns ICU was 15 (13–25) days and the time from onset of the cutaneous signs until complete re-epithelialisation was 24 days (13–55) for the seven survivors. Five patients fulfilled the diagnostic criteria of sepsis. One patient with extensive ischaemic cardiac disease developed septic shock and died (mortality 12.5 %). Two patients developed side effects from PE.¶Conclusions: To our knowledge, this is the largest series yet presented using PE in the treatment of TEN. Our results, in patients with less cutaneous involvement, similar causative agents, and similar demographic data as in the other two studies (controls), were no different as far as mortality, length of stay, or time to re-epithelialisation were concerned. This finding does not support the use of PE in the treatment of TEN.     

Quality of life before intensive care admission: agreement between patient and relative assessment

Objective: To assess the agreement between patients and relatives concerning the formers’ quality of life (QOL) before intensive care unit (ICU) admission.¶Design: Prospective study involving direct interviews of patients and relatives during ICU stay.¶Setting: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital.¶Patients and methods: A hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h, and their relatives were interviewed. The instruments used were two questionnaires suitable for ICU patients: QOL-IT and QOL-SP. Interobserver reproducibility was investigated in 36 patients.¶Results: Interobserver reproducibility was nearly perfect (weighted Kappa 0.99 for QOL-IT and QOL-SP). Considering global scores, weighted Kappa was 0.78 for QOL-IT and 0.82 for QOL-SP, with the mean difference between patients and relatives lower than 0.3 for both scores but with limits of agreement wider than 4. Among the items, concordance was excellent in the areas of physical activity and social life for both questionnaires. Gender, living together with the patient and the degree of relationship of relatives did not influence the agreement.¶Conclusions: The relatives give global scores for both instruments which can be regarded as acceptable substitutes for those given by patients. However, the wide limits of agreement should make investigators cautious in analysing together scores generated by patients and by relatives. The emotional dimension seems to be assessed less accurately by relatives than the physical one.     

Preliminary results on nursing workload in a dedicated weaning center

Objective: To evaluate the nursing time required for difficult-to-wean patients in a dedicated weaning center (WC) and to examine the correlation of the nursing time with nursing workload (NW) scores and with clinical severity and dependency.¶Setting: Four-bed WC of a pulmonary rehabilitation department.¶Intervention: None.¶Design and measurement: Prospective, observational study of 46 consecutive patients admitted to a long-term WC. Time required by items of the Time Oriented Score System (TOSS) and other tasks specific to respiratory intermediate intensive care units were evaluated for all the activities performed on each patient in the first 2 days after admission. Patient dependency and level of nursing care at admission were measured using the Dependence Nursing Scale (DNS) and the Intermediate Therapeutic Intervention Score System (TISS-int). The Acute Physiology and Chronic Health Evaluation (APACHE) II score was also recorded at admission.¶Results: On the first day each patient needed 45 ± 15 % (63 ± 23 %, 45 ± 22 %, and 29 ± 14 % for the three nursing shifts) of allocated single nursing time. On the TOSS on the first day patients required a daily mean 28 ± 10 % of total available nursing time; on the second day the results did not change. Time of care in the first 24 h was only weakly related to DNS, APACHE II score, and TISS-int; only DNS was able (although weakly; r = 0.45) to predict minutes of nursing care.¶Conclusions: In difficult-to-wean patients from mechanical ventilation the nursing time in the first 2 days after admission is high. The use of TOSS may underestimate NW by about 38 %. Although only DNS showed the ability to predict minutes of care, the weak relationship limits its value in clinical practice.     

Predictors of short-term mortality in critically ill patients with solid malignancies

Admission of cancer patients with serious medical complications to the ICU remains controversial primarily because of the high short-term mortality rates in these patients. However, the cancer patient population is heterogeneous regarding age, underlying conditions, and curability of their disease, suggesting that large variations may occur in the effectiveness of intensive care within this subgroup of critically ill patients.¶Objectives: To identify factors predicting 30-day mortality in patients with solid tumors admitted to a medical ICU.¶Patients and methods: We conducted a retrospective study in 120 consecutive cancer patients (excluding patients with hematological malignancies) admitted to the medical ICU of a 650-bed university hospital between January 1990 and July 1997. Medical history, physical and laboratory test findings at admission, and therapeutic interventions within the first 24 h in the ICU were recorded. The study endpoint was vital status 30 days after ICU admission. Stepwise logistic regression was used to identify independent prognostic factors.¶Results: The observed 30-day mortality rate was 58.7 % (n = 68), with most deaths (92 %) occurring in the ICU. Univariate predictors of 30-day mortality were either protective [prior surgery for the cancer (p = 0.01) and complete remission (p = 0.01)] or associated with higher mortality [Knaus scale C or D (p = 0.02), shock (p = 0.04), need for vasopressors (p = 0.0006) or for mechanical ventilation (p = 0.0001), SAPS II score greater than 36 (p = 0.0001), LOD score greater than 6 (p = 0.0001), and ODIN score > 2 (p = 0.0001)]. Three variables were independent predictors: previous surgery for the cancer (OR 0.20, 95 % CI 0.07–0.58), LOD score > 6 (OR 1.26, 95 % CI 1.09–1.44), and need for mechanical ventilation (OR 3.55, 95 % CI; 1.26–6.7). Variables previously thought to be indicative of a poor prognosis (i. e., advanced age, metastatic or progressive disease, neutropenia or bone marrow transplantation) were not predictive of outcome.¶Conclusion: When transfer to an ICU is considered an option by patients and physicians, 30-day mortality is better estimated by an evaluation of acute organ dysfunction than by the characteristics of the underlying malignancy.     

Acute renal failure in patients over 80 years old: 25-years' experience

Objective: To determine the epidemiological trends, spectrum of etiologies, morbidity and mortality of acute renal failure (ARF) in patients over 80 years old.¶Design: Historical cohort analysis.¶Setting: Intensive care unit (ICU) of nephrology, Tenon Hospital, Paris.¶Patients and participants: The criteria of inclusion was ARF, defined on the basis of a creatinine value over 120 μmol/l, in patients over 80 years of age admitted between October 1971 and September 1996. When moderate chronic nephropathy was pre-existing, ARF was defined by the increase of at least 50 % over the basal creatininemia.¶Measurements and results: Three hundred and eighty-one patients over 80 years of age were included. The etiology and mechanism of ARF are detailed. 29 % of the patients received dialysis. Global mortality at the hospital was 40 %. Factors significantly associated with a poor prognosis are identified. Mean survival after hospitalization was 19 months.¶Conclusion: The frequency of admission to ICUs for ARF in patients older than 80 years seems to be on the increase. Mortality is less severe than expected. These patients could benefit from the renal replacement therapy of modern intensive care medicine.     

Effects of prone position on alveolar recruitment and oxygenation in acute lung injury

Objective: To investigate the effects of prone position (PP) on alveolar recruitment and oxygenation in acute respiratory failure.¶Design: Prospective physiologic study.¶Setting: Medical ICU two in a university hospital.¶Patients: Twelve adult patients intubated and mechanically ventilated with medical primary acute lung injury/adult respiratory distress syndrome (ALI/ARDS) in whom PP was indicated.¶Measurements and results: We constructed the static inflation volume-pressure curves (V-P) of the respiratory system in the 12 patients and differentiated between lung and chest wall in ten of them. We determined the difference between end-expiratory lung volume on positive end-expiratory pressure (PEEP) and relaxation volume of the respiratory system on zero PEEP (ΔFRC). The recruited alveolar volume was computed as the ΔFRC times the ratio of static elastance of the respiratory system to the lung. These measurements together with arterial blood gases determination were made in supine position (SP1), after 1 h of PP and after 1 h of supine repositioning (SP2) at the same level of PEEP. The PaO₂/FIO₂ ratio improved from SP1 to PP (136 ± 17 vs 204 ± 24 mm Hg; p < 0.01). An PP-induced alveolar recruitment was found in five patients. The change in oxygenation correlated to the recruited volume. The static elastance of the chest wall decreased from 4.62 ± 0.99 cmH₂O/l in SP1 to 6.26 ± 0.54 cmH₂O/l in PP (p < 0.05) without any correlation to the change in oxygenation.¶Conclusions: Alveolar recruitment may be a mechanism of oxygenation improvement in some patients with acute hypoxemic respiratory failure. No correlation was found between change in oxygenation and chest wall elastic properties.     

Angiotensin II formation and endothelin clearance in ARDS patients in supine and prone positions

Objective: In patients with acute respiratory distress syndrome (ARDS), the prone position may enhance oxygenation by changing ventilation/perfusion ratio. In this study, we investigated whether the prone position affects the net balance between pulmonary endothelin (ET-1) and angiotensin II (Ang II) production and clearance, two metabolic functions of lung endothelial cells.¶Setting: Anaesthesiological intensive care unit of a university hospital.¶Patients: Ten ARDS patients (Murray score > 2.5) were studied in both the supine position (SP) and the prone position (PP).¶Measurements and design: Blood samples were taken simultaneously from the patient in SP for assessment of mixed venous and arterial ET-1 and Ang II concentrations, and plasma renin concentration (PRC). This was repeated after 60 min in SP, immediately after turning the patient into PP, and 60 min thereafter. Net arterial/mixed venous ET-1 clearances and net Ang II formations were calculated.¶Results: arterial oxygen tension increased from SP to PP by an average of 60 mmHg, about 20 %. Arterial ET-1 concentrations of ARDS patients were 1.57 ± 1.1 pg/ml (mean ± SD) and within the range of healthy persons. Net ET-1 clearances were negative in SP, indicating pulmonary release of ET-1, and did not change in PP. Arterial Ang II concentrations (73 ± 56 pg/ml) as well as PRC (126 ± 85 pg/ml) were markedly elevated. Net transpulmonary Ang II formation did not change.¶Conclusion: Acute changes of oxygenation in ARDS patients by positioning do not induce any short-term effects on pulmonary ET-1 net clearance or Ang II net formation.     

Interobserver variability of the measurement of the mortality probability models (MPM II) in the assessment of severity of illness

Objective: To assess the interobserver variability of the measurement of the MPM II system.¶Design: Random sample of an inception cohort.¶Setting: Fifteen adult medical and surgical intensive care units (ICUs) in Spain.¶Patients: A 5 % random sample (n = 119) of 2332 patients consecutively admitted in the ICU, aged 18 years or older.¶Interventions: Prospective data collection during the stay of the patient in the ICU. Repeated data collection, after the patient's hospital discharge.¶Measurements and main results: Demographic information, length-of-stay and vital status at both ICU and hospital discharge, as well as all variables necessary for computing the MPM II system were measured. Interobserver variability for categorical variables was measured computing the kappa index. For interval variables the interobserver variability was assessed by the intraclass correlation coefficient, the paired t-test, and linear regression.¶In the MPM II₀ index, the variables coma, heart rate, systolic blood pressure, chronic renal insufficiency, metastatic neoplasm, acute renal failure, cardiac dysrhythmia and cardiopulmonary resuscitation, showed moderate or low levels of agreement. In the MPM II₂₄ index, the variables coma or deep stupor, PaO₂ and prothrombin time showed low or moderate interobserver agreement. Agreement for the MPM II probability of death was high, although the external observer obtained a lower estimation than the hospital observer.¶Conclusions: The MPM II severity system showed a high level of stability when used in groups of patients. Nevertheless, the observed variability in some variables means that it should be used with caution for individual patients.     

Influence of social deprivation on intensive care outcome

Objective: To assess the influence of social deprivation on outcome from admission to the intensive care unit. Design: Retrospective cohort study. Setting: Tertiary referral centre mixed adult intensive care unit (ICU). Patients: Seven hundred seventy-four consecutive admissions to the ICU over a 2-year period. Interventions: None.¶Measurements and results: Age, admission illness severity measured by APACHE II score, predicted hospital mortality, actual hospital mortality and length of ICU stay were obtained for all patients. Social deprivation was assessed by Carstairs Score for postcode sector of residence categorised from 1 (most affluent ) to 7 (most deprived). Carstairs Scores were obtained for 716 patients. When patients in categories 6 and 7 were compared with the others there were no significant differences in age, admission illness severity, predicted or actual hospital mortality and length of ICU stay. On multivariate analysis there was no evidence of an increased mortality risk for patients in categories 6 and 7 (p = 0.256, odds ratio 1.2, 95 % confidence interval 0.9–1.7). Conclusions: Social deprivation does not influence outcome in patients admitted to the ICU.     

Outcomes of critically ill cancer patients with Acinetobacter baumannii infection

AIM: To describe the intensive care unit(ICU) outcomes of critically ill cancer patients with Acinetobacter baumannii(AB) infection.METHODS: This was an observational study that included 23 consecutive cancer patients who acquired AB infections during their stay at ICU of the National Cancer Institute of Mexico(INCan), located in Mexico City. Data collection took place between January 2011, and December 2012. Patients who had AB infections before ICU admission, and infections that occurred during the first 2 d of ICU stay were excluded. Data were obtained by reviewing the electronic health record of each patient. This investigation was approved by the Scientific and Ethics Committees at INCan. Because of its observational nature, informed consent of the patients was not required.RESULTS: Throughout the study period, a total of 494 critically ill patients with cancer were admitted to the ICU of the INCan, 23(4.6%) of whom developed AB infections. Sixteen(60.9%) of these patients had hematologic malignancies. Most frequent reasons for ICU admission were severe sepsis or septic shock(56.2%) and postoperative care(21.7%). The respiratory tract was the most frequent site of AB infection(91.3%). The most common organ dysfunction observed in our group of patients were the respiratory(100%), cardiovascular(100%), hepatic(73.9%) and renal dysfunction(65.2%). The ICU mortality of patients with 3 or less organ system dysfunctions was 11.7%(2/17) compared with 66.6%(4/6) for the group of patients with 4 or more organ system dysfunctions(P = 0.021). Multivariate analysis identified blood lactate levels(BLL) as the only variable independently associated with inICU death(OR = 2.59, 95%CI: 1.04-6.43, P = 0.040). ICU and hospital mortality rates were 26.1% and 43.5%, respectively.CONCLUSION: The mortality rate in critically ill patients with both HM, and AB infections who are admitted to the ICU is high. The variable most associated with increased mortality was a BLL ≥ 2.6 mmol/L in the first day of stay in the ICU.     

The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation

OBJECTIVE: Cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission. We designed a prospective study evaluating a new admission policy titled The ICU Trial. DESIGN: Prospective study. SETTING: Intensive care unit. PATIENTS: One hundred eighty-eight patients requiring mechanical ventilation and having at least one other organ failure. INTERVENTIONS: Over a 3-yr period, all patients with hematologic malignancies or solid tumors proposed for ICU admission underwent a triage procedure. Bedridden patients and patients in whom palliative care was the only cancer treatment option were not admitted to the ICU. Patients at earliest phase of the malignancy (diagnosis < 30 days) were admitted without any restriction. All other patients were prospectively included in The ICU Trial, consisting of a full-code ICU admission followed by reappraisal of the level of care on day 5. MEASUREMENTS AND MAIN RESULTS: Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness. Hospital survival was 21.8% overall. Among the 103 survivors on day 5, none of the characteristics of the malignancy were significantly different between the 62 patients who died and the 41 who survived. Time course of organ dysfunction over the first 6 ICU days differed significantly between survivors and nonsurvivors. Organ failure scores were more accurate on day 6 than at admission or on day 3 for predicting survival. All patients who required initiation of mechanical ventilation, vasopressors, or dialysis after 3 days in the ICU died. CONCLUSIONS: Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 21.8% overall. If these results are confirmed in future interventional studies, we recommend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan-extending cancer treatment is available.     

Severe infantile hypothermia: short- and long-term outcome

Objective: To determine short- and long-term outcomes of infants with severe hypothermia (≤ 28 °C) treated in a pediatric intensive care unit (PICU).¶Design: (1) Retrospective evaluation of medical records of all patients admitted for severe infantile hypothermia from 1984 to 1993. (2) Medical and developmental evaluations of survivors of severe infantile hypothermia 3–12 years after hospital discharge.¶Setting: Six-bed PICU of a university teaching hospital.¶Patients: Eighteen infants who arrived at the emergency room with a rectal temperature between 20 and 28 °C.¶Measurements and results: The ages of patients ranged between 5 and 30 days. Fifteen were Bedouins and three were Jews. Clinical features included sepsis in 9 (septic shock in 5 of 9) patients, respiratory failure in 11 and overt bleeding in 5. Rewarming was applied using rapid external warming under a radiant heater. Five infants died shortly after arrival and one patient at age 6 years; all of them had sepsis on arrival. Of the 12 survivors examined at ages 3–12 years, ten had normal psychomotor achievements, while the remaining two had mild (1 patient) and severe (1 patient) psychomotor retardation. Both of the latter two had sepsis on first admission for hypothermia. All nine hypothermic infants, who had no sepsis, had normal medical examinations and normal developmental achievements for their ages.¶Conclusion: Severe infantile hypothermia is a serious condition. When treating patients in a modern PICU, morbidity and mortality are mainly related to the presence or absence of an associated septicemia. Infants without septicemia may have normal growth and development.     

AUDIT OF IMPORTED AND DOMESTIC MALARIA CASES AT KUALA LUMPUR HOSPITAL

SUMMARY The clinical, haematological and biochemical profiles of all domestic and imported malaria cases admitted to the Hospital Kuala Lumpur were analysed. The most common malaria types were Plasmodium falciparum (39.5%) and Plasmodium vivax (42%). The most common patient type was men aged 29-40 years (reflecting the high mobility of this group, many of whom were illegal immigrants). Misdiagnosis on admission was frequently due to the variable clinical presentation of the disease and the difficulties of obtaining an accurate history. Associated haematological abnormalities were common. Chloroquine resistance was diagnosed in four P. falciparum patients and in one P. falciparum/vivax patient. Overall, imported malaria did not seem more severe than domestic. The three patients with cerebral malaria survived. One patient died of acute liver failure. The large influx of illegal immigrants to Malaysia has resulted in a surge in malaria infection; illegal immigrants remain a source of chloroquine resistance.     

Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients

Objective: The inter-hospital transfer of critically ill patients in the United Kingdom is commonly undertaken using standard ambulance under junior doctor escort, despite recommendations for the use of specialist retrieval teams. Patients are transferred into University College London Hospitals (UCLH) intensive care unit (ICU) by both methods. We undertook to evaluate the effect of transfer method on acute physiology (within 2 h of ICU admission) and early mortality ( < 12 h after ICU admission).¶Design: Retrospective review of all transfers over 1 year.¶Setting: UCLH ICU.¶Subjects: 259 transfers; 168 by specialist retrieval team (group A) and 91 by standard ambulance with doctor provided by referring hospital (group B).¶Interventions: None¶Main outcome measures: Acute physiology (pH, PaO₂, PaCO₂, heart rate (HR), mean arterial blood pressure (MAP), 24 h severity of illness scores (APACHE II, SAPS II), length of stay and mortality.¶Results: There were no differences in demographic characteristics or severity of illness between the two groups; nevertheless significantly more patients in group B than in group A were severely acidotic (pH < 7.1: 11 % vs. 3 %, p < 0.008) and hypotensive (MAP < 60: 18 % vs. 9 %, p < 0.03) upon arrival. In addition, there were more deaths within the first 12 h after admission with 7.7 % deaths (7/91) in group B transfers vs. 3 % (5/168) in group A.¶Conclusions: The use of a specialist transfer team may significantly improve the acute physiology of critically ill patients and may reduce early mortality in ICU.