Prospective evaluation of a modified Early Warning Score to aid earlier detection of patients developing critical illness on a general surgical ward

Admissions to the intensive care unit (ICU) from the wards havea higher mortality when compared to patients admitted from theoperating theatres/recovery and accident and emergency department.¹Suboptimal care may contribute to morbidity and mortality ofpatients admitted from the ward.² Failure to appreciate physiologicalderangements of breathing and mental status has been demonstratedin patients who subsequently suffered cardiac arrest, and theseevents may have been apparent up to 8 h prior to the event.³⁴ The Early Warning Score (EWS) was developed as a simple scoringsystem to be used at ward level utilising routine observationstaken by nursing staff.⁵ Deviations from the normal score pointsand a total is calculated. The EWS was evaluated prospectively for 1 month. The score wasthen modified to include urine output, to make temperature deviationsless sensitive and to include normalised blood pressure (Table8). We then evaluated this prospectively for 9 months. A total score of 4 or more resulted in the patient being reviewedby ward medical staff and help sought from the intensive careteam if appropriate. Over a 9-month period 206 patients on twogeneral surgical wards were put on the scoring system, of these26 were admitted to the ICU. The APACHE II scores of these patientswas 16.6 (± 7.3). Eleven patients were admitted to theICU from the surgical ward who had not been monitored on themodified EWS and their admission APACHE II scores were 23.5(± 4.1). This compares with admission APACHE II scoresof 22.3 (± 5.5) in 43 patients admitted from surgicalwards in the 9-month period prior to introduction of the system.The introduction of the system has appeared to lead to earlierreferral to the intensive care unit.     

Surgical critical care--a rose by any other name

Editor—Many of us have worked with inadequate provisionof level 2 and 3 beds, which leads to cancelled elective surgeryand substandard care of patients on general wards or in an inadequatelystaffed recovery area. Dr Aps has been able to fill a gap inpatient care by developing an overnight intensive recovery (OIR)area.¹ The unit that he has established would be recognizedby many as an intensive care unit: bed spaces equipped to level3 standard; 1:1     

PLASMA LIGNOCAINE CONCENTRATIONS ASSOCIATED WITH EXTRADURAL ANALGESIA IN PATIENTS WITH AND WITHOUT MULTIPLE ORGAN FAILURE

We have measured plasma concentrations of ligno-caine afterthoracic extradural analgesia with continuous infusion of lignocainein eight intensive care patients with chest wall trauma or aftermajor upper abdominal surgery. Four patients developed multipleorgan failure (MOF). Plasma concentrations of lignocaine inarterial blood were measured 4, 8, 24 and 48 h after a continuousinfusion of lignocaine was commenced in the extradural space.Plasma concentrations of lignocaine were greater in all patientswith MOF (range 2.7–5.1 ng ml^–1) than in patientswithout MOF (range 0.8–1.2 fig mh^–1). Because plasmaconcentrations in patients with MOF were within the low toxicrange, extradural infusion of lignocaine should only be consideredin intensive care patients without MOF or when plasma concentrationsof lignocaine are monitored. (Br. J. Anaesth. 1992;69:513–516)     

POSTOPERATIVE SPINAL ANALGESIA WITH MORPHINE

Patients with pain after operation received morphine hydrochlorideintrathecally in doses of 0.02mg kg^– (n = 30) and 0.2mgkg(n = 30). The high-dose group showed slightly longer-lastingand more potent analgesia than the low-dose group. Sedation,decrcases in heart rate and systolic arterial pressure, oliguria,nausea and urinary retention were more frequent in the high-dosegroup. Two patients of the high-dose group showed evidence ofrespiratory depression which appeared after a late change inposture (7 and 11 h). We conclude that postoperative analgesiawith intrathecal morphine 0.02mg kg^–1 must be followedby a prolonged head-up posture and be performed in hospitalunits where the treatment of respiratory depression is competent.     

Nursing problems in patients with toxic epidermal necrolysis and Stevens-Johnson syndrome in a Dutch burn centre: A 30-year retrospective study

ObjectiveMultiple studies have been published on toxic epidermal necrolysis (TEN) and Stevens-Johnsen syndrome (SJS). Nursing care is an important part of the treatment of TEN patients. Unfortunately, limited information on nursing in TEN/SJS patients has been published in the current literature. Nursing research is needed to improve the complex nursing care required for these rare patients. Therefore, the objective was to assess nursing problems in TEN patients in a burn centre setting over a 30-year period.MethodsThe data for this study were gathered retrospectively from nursing records of all patients with TEN/SJS admitted to Burn Centre Rotterdam between January 1987 and December 2016. Dutch burn centres were recently accepted as expertise centres for TEN patients. Nursing problems were classified using the classification of nursing problems of the Dutch Nursing Society.ResultsA total of 69 patients were admitted with SJS/TEN. Fifty-nine patient files were available. The most frequently reported nursing problems (>20% of the patients) were wounds, threatened or disrupted vital functions, dehydration or fluid imbalance, pain, secretion problems and fever. Furthermore, TEN-specific nursing problems were documented, including oral mucosal lesions and ocular problems. The highest number of concomitant nursing problems occurred during the period between days three and 20 after onset of the disease and varied by nursing problem.ConclusionsThe most frequently reported nursing problems involved physical functions, especially on days three to 20 after onset of the disease. With this knowledge, we can start nursing interventions early in the treatment, address problems at the first sign and inform patients and their families or relatives of these issues early in the disease process. A next step to improve nursing care for TEN patients is to acquire knowledge on the optimal interventions for nursing problems.     

THE USE OF DIFFERENT DOSES OF VECURONIUM IN PATIENTS WITH LIVER DYSFUNCTION

The clinical neuromuscular effects of two doses of vecuronium(0.15 mg kg^-1 and 0.2 mg kg^-1) were investigated in 20 healthypatients and 20 patients with cirrhosis, and compared with previouswork in which vecuronium 0.1 mg kg^-1 was given under identicalconditions of anaesthesia and monitoring. Ten healthy patientsreceived vecuronium 0.15 mg kg^-1 and 10 received 0.2 mg kg^-1.Similarly, 10 patients with cirrhosis received vecuronium 0.15mg kg^-1 and 10 received 0.2 mg kg^-1. Vecuronium 0.1 mg kg^-1has previously been shown to have a somewhat shorter durationof action in cirrhotic as opposed to healthy patients. In thisstudy, vecuronium 0.15 mg kg^-1 was found to have a similar durationof action in both groups, and vecuronium 0.2 mg kg^-1 had a significantlylonger action in the cirrhotic group. It is suggested that vecuroniumshould be used with caution in patients with hepatic dysfunctionand that, in such patients, monitoring of neuromuscular functionis desirable.     

CLINICAL EXPERIENCE AND PLASMA LAUDANOSINE CONCENTRATIONS DURING THE INFUSION OF ATRACURIUM IN THE INTENSIVE THERAPY UNIT

Twenty patients in the intensive care unit received an infusionof atracurium to permit mechanical ventilation. The durationof infusion ranged from 38 to 219 h and the average rate ofinfusion during the study was 0.76 mg kg^–1 h^–1.In 14 patients an increase in atracurium requirement occurredwithin the first 72 h of the infusion. Recovery from neuromuscularblockade after a prolonged infusion was sufficiently rapid toavoid pharmacologically induced reversal. In six patients maximumplasma concentrations of laudanosine were 1.9–5 µgml^–1 and there was no evidence of cerebral excitation.     

DOSE REQUIREMENTS OF ATRACURIUM IN PAEDIATRIC INTENSIVE CARE PATIENTS

The dose requirements of atracurium were determined in 12 childrenwho required an infusion of atracurium to facilitate mechanicalventilation in the intensive care unit. The mean duration ofinfusion was 98 h (range 36-284 h) during which an increasingdose requirement was observed in all patients. The mean infusionrate was 1.60 (semO.08) mgkg^–1 h^–1, and in sevenpatients a mean infusion rate of 1.72 (0.15) mg kg^–1 h^–1was observed at 72 h. These rates are greater than those reportedpreviously in adults. Cessation of neuromuscular block occurredpromptly upon discontinuing the infusion. No side effects wereobserved which could be attributed to the infusion of atracurium.     

Fast-tracking (bypassing the PACU) does not reduce nursing workload after ambulatory surgery

Background. Postoperative day-case patients are usually allowedto recover from anaesthesia in a postanaesthesia care unit (PACU)before transfer back to the day surgical unit (DSU). Bypassingthe PACU can decrease recovery time after day surgery. Costsavings may result from a reduced nursing workload associatedwith the decreased recovery time. This study was designed toevaluate the effects of bypassing the PACU on patient recoverytime and nursing workload and costs. Methods. Two hundred and seven consenting outpatients undergoingday surgery procedures were enrolled. Anaesthesia was inducedand maintained with a standardized technique and the electroencephalographicbispectral index was monitored and maintained at 40–60during anaesthetic maintenance. At the end of surgery, patientswere randomly assigned to either a routine or fast-tracking(FT) group. Patients in the FT group were transferred from theoperating room to the DSU (i.e. bypassing the PACU) if theyachieved the FT criteria. All other patients were transferredto the PACU and then to the DSU. Nursing workload was evaluatedusing a patient care hour chart based on the type and frequencyof nursing interventions in the PACU and DSU. A cost associatedwith the nursing workload was calculated. Results. The overall time from end of anaesthesia to dischargehome was significantly decreased in the fast-tracking group.However, overall patient care hours and costs were similar inthe two recovery groups. Conclusion. Bypassing the PACU after these short outpatientprocedures significantly decreases recovery time without compromisingpatient satisfaction. However, the overall nursing workloadand the associated cost were not significantly affected.      

A simple method for calculating the required size of a high dependency unit

As part of a business plan for the establishment of a high dependencyunit (HDU) in a 742 bedded acute teaching hospital, a studywas carried out to establish the number of beds required. Thehospital already had a six-bed intensive care unit (ICU), witha seventh bed staffed part-time to provide postoperative carefor elective surgical cases. Over a 2-week period, one investigator(JAG) visited each of 16 acute wards daily, to identify patientsappropriate for HDU admission. He also visited the ICU to identifyany patients for whom HDU would provide a step-down facility,and examined operating theatre recovery records to identifyany patients who could not be returned to the general ward within3 h following their surgery. At each visit, the nurse in charge was asked to identify anypatients requiring additional nursing care or in need of increasedmonitoring. Each patient was assessed using the TherapeuticIntervention Scoring System (TISS).¹ A score of greater than10 indicated suitability for HDU admission. Physiological andbiochemical data were also collected to allow calculation ofeach patient’s Simplified Acute Physiology Score (SAPSII)² and hence calculation of predicted mortality. During the 14 day period, 35 patients were identified as requiringadditional care. Their mean TISS score was 14.1 (range 10–33)and their mean predicted mortality was 5.7% (0–19.6%).Each patient had a predicted average HDU stay of 2.2 days (1–5days) to give a total of 76 patient days. The occupancy of theproposed HDU ranged from 3 to 8 patients per day with a meanof 5.4 per day, suggesting that an HDU containing a minimumof six beds would be appropriate to serve the needs of the hospital.     

Propofol 6% as sedative in children under 2 years of age following major craniofacial surgery

Background. After alarming reports concerning deaths after sedationwith propofol, infusion of this drug was contraindicated bythe US Food and Drug Administration in children <18 yr receivingintensive care. We describe our experiences with propofol 6%,a new formula, during postoperative sedation in non-ventilatedchildren following craniofacial surgery. Methods. In a prospective cohort study, children admitted tothe paediatric surgical intensive care unit following majorcraniofacial surgery were randomly allocated to sedation withpropofol 6% or midazolam, if judged necessary on the basis ofa COMFORT behaviour score. Exclusion criteria were respiratoryinfection, allergy for proteins, propofol or midazolam, hypertriglyceridaemia,familial hypercholesterolaemia or epilepsy. We assessed thesafety of propofol 6% with triglycerides (TG) and creatine phosphokinase(CPK) levels, blood gases and physiological parameters. Efficacywas assessed using the COMFORT behaviour scale, Visual AnalogueScale and Bispectral Index^TM monitor. Results. Twenty-two children were treated with propofol 6%,23 were treated with midazolam and 10 other children did notneed sedation. The median age was 10 (IQR 3–17) monthsin all groups. Median duration of infusion was 11 (range 6–18)h for propofol 6% and 14 (range 5–17) h for midazolam.TG levels remained normal and no metabolic acidosis or adverseevents were observed during propofol or midazolam infusion.Four patients had increased CPK levels. Conclusion. We did not encounter any problems using propofol6% as a sedative in children with a median age of 10 (IQR 3–17)months, with dosages <4 mg kg^–1 h^–1 during amedian period of 11 (range 6–18) h.      

INCREASED CARBON DIOXIDE PRODUCTION IN TWO PATIENTS WITH MALIGNANT HYPERPYREXIA AND ITS CONTROL BY DANTROLENE

Two patients with successfully treated malignant hyperpyrexiaare reported. Carbon dioxide output, calculated from the respiratoryminute volume and P_CO2 was found to be greatly increased inboth patients. In the patient who received dantrolene 7.5 mgkg^–1 the carbon dioxide output decreased rapidly to normalvalues, whereas in the other patient carbon dioxide output remainedincreased for several hours.     

Management of life-threatening autonomic hyper-reflexia using magnesium sulphate in a patient with a high spinal cord injury in the intensive care unit

We report the successful use of i.v. magnesium sulphate to controllife-threatening autonomic hyper-reflexia associated with chronicspinal cord injury in the intensive care environment. A 37-yr-old,male was admitted to the intensive care unit with a diagnosisof septic shock and acute renal failure secondary to pyelonephritis.He had been found unresponsive at home following a 2-day historyof pyrexia and purulent discharge from his suprapubic catheter.He had sustained a T5 spinal cord transection 20 yr previously.Initial management included assisted ventilation, fluid resuscitation,vasopressor support, and continuous veno-venous haemofiltration.The sepsis was treated with antibiotic therapy and percutaneousnephrostomy drainage of the pyonephrosis. On the fifth day,the patient developed profuse diarrhoea. This was associatedwith paroxysms of systemic hypertension and diaphoresis, hisarterial pressure rising on occasion to 240/140 mm Hg. A diagnosisof autonomic hyper-reflexia was made and a bolus dose of magnesiumsulphate 5 g was administered over 15 min followed by an infusionof 1–2 g h^–1. There was an almost immediate decreasein the severity and frequency of the hypertensive episodes.There were no adverse cardiac effects associated with the administrationof magnesium, only a slight decrease in minute ventilation asthe plasma level approached the upper end of the therapeuticrange (2–4 mmol litre^–1). In view of the beneficialeffects observed in this case we advocate further research intothe use of magnesium sulphate in the treatment or preventionof autonomic hyper-reflexia secondary to chronic spinal cordinjury in the intensive care unit. Br J Anaesth 2002; 88: 434–8     

Corticosteroids for septic shock--a standard of care?

Septic shock has a crude mortality rate of 45% and claims thelives of 90 000 people each year in the USA alone.¹ An epidemiologicalstudy from France of over 100 000 intensive care unit (ICU)admissions indicates the incidence of septic shock before orfollowing admission to ICU is rising and now affects almost10% of this patient population.² Given the scale and associatedcosts of this problem,^{3 4} it is not surprising that developingsolutions has been a focus of researchers, clinicians, and thepharmaceutical industry. Despite many past disappointments particularlywith antagonists of endogenous mediators,⁵ some recent approacheshave shown promise in prevention or treatment of sepsis     

Leipziger „Fast-track“-Protokoll in der Kardioanästhesie

Background

In November 2005 a complex, multimodal anesthesia fast-track protocol (FTP) was introduced for elective cardiac surgery patients in the Cardiac Center of the University of Leipzig which included changing from an opioid regime to remifentanil and postoperative treatment in a special post-anesthesia recovery and care unit. The goal was to speed up recovery times while maintaining safety and improving costs.

Method

A total of 421 patients who underwent the FTP and were treated in the special recovery room were analyzed retrospectively. These patients were compared with patients who had been treated by a standard protocol (SP) prior to instituting the FTP. Primary outcomes were time to extubation, length of stay in the intensive care unit (ICU) and treatment costs.

Results

The times to extubation were significantly shorter in the FTP group with 75 min (range 45–110 min) compared to 900 min (range 600–1140 min) in the SP group. Intensive care unit stay and hospital length of stay were also significantly shorter in the FTP group (p<0.01). The reduction of treatment costs of intensive care for FTP patients was 53.5% corresponding to savings of EUR 738 per patient in the FTP group compared with the SP group.

Conclusions

The Leipzig fast-track protocol for cardio-anesthesia including the central elements of switching opiate therapy to remifentanil and switching patient recovery to a special post-anesthesia recovery and care unit, shortened therapy times, is safe and economically effective.     

Interdisciplinary communication in the intensive care unit

BACKGROUND: Patient safety research has shown poor communication among intensivecare unit (ICU) nurses and doctors to be a common causal factorunderlying critical incidents in intensive care. This studyexamines whether ICU doctors and nurses have a shared perceptionof interdisciplinary communication in the UK ICU. METHODS: Cross-sectional survey of ICU nurses and doctors in four UKhospitals using a previously established measure of ICU interdisciplinarycollaboration. RESULTS: A sample of 48 doctors and 136 nurses (47% response rate) fromfour ICUs responded to the survey. Nurses and doctors were foundto have differing perceptions of interdisciplinary communication,with nurses reporting lower levels of communication opennessbetween nurses and doctors. Compared with senior doctors, traineedoctors also reported lower levels of communication opennessbetween doctors. A regression path analysis revealed that communicationopenness among ICU team members predicted the degree to whichindividuals reported understanding their patient care goals(^adjR² = 0.17). It also showed that perceptions of the qualityof unit leadership predicted open communication. CONCLUSIONS: Members of ICU teams have divergent perceptions of their communicationwith one another. Communication openness among team membersis also associated with the degree to which they understandpatient care goals. It is necessary to create an atmospherewhere team members feel they can communicate openly withoutfear of reprisal or embarrassment.     

Sedating patients undergoing mechanical ventilation in the intensive care unit--winds of change?

The majority of mechanically ventilated patients in the intensivecare unit (ICU) require sedation to reduce anxiety, encouragesleep and to increase tolerance to tracheal tubes and the ventilator.Sedative and analgesic drugs are amongst the most commonly prescribedmedications in the ICU.¹ The choice of agent and the way inwhich they are used varies widely between and within ICUs. Ina survey of 164 ICUs in the US,² 18 different sedative agentswere used, the commonest of which were the opiates and benzodiazepines.A more recent study³ revealed substantial differences in theclinical use of drugs for sedation and analgesia in the westernEuropean countries surveyed.  These differences in clinical practice can have an importantimpact on patient outcome and cost of care: excessively deep     

Incidence of infections in patients with status epilepticus requiring intensive care and effect on resource utilization

Data from a six-year period were retrospectively retrieved from medical records and an intensive care unit data management system to study the impact of infections on patients with status epilepticus. Out of 161 admitted patients, 33 had a community-acquired infection and 35 acquired an infection during their hospital stay, 10 while in a ward before admission to the intensive care unit and 25 while in an intensive care unit, giving an infection rate of 42% of all admissions (68 patients). The patients with intensive care unit-acquired infection had three times longer stays in the intensive care unit than those without any infection (P<0.001), and they utilized almost four times more nursing resources than those without infections (P<0.001). Furthermore, they were more often sedated with thiopentone infusion, either alone or in combination with other drugs, than the non-infectious patients (80% vs 20%, P <0.001). Both community- and hospital-acquired infections were related to longer intensive care unit stays (P<0.001). The hospital stay of patients with hospital-acquired infection was threefold compared to that of patients without infection (P<0.001), and these patients utilized almost three times more nursing resources than those without any infection (P<0.001). Patients with infections consumed 65.5% of the intensive care unit nursing resources of status epilepticus patients. In conclusion, the infection rate of status epilepticus patients was high and nosocomial infections were associated with more severe illness, treatment escalation, prolonged hospital stay and enhanced resource utilization.     

One year outcome of intensive care patients with decompensated alcoholic liver disease

Background. We aimed to examine the outcome of patients withdecompensated alcoholic liver disease (ALD) admitted to a generalintensive care unit (ICU). Methods. Retrospective observational cohort study of intensivecare admissions over a 3 yr period was conducted. The studywas set in an ICU in a UK university hospital with a tertiaryliver referral unit. One hundred and ten admissions, involving107 patients, with decompensated ALD were included. Intensivecare, hospital, and 6 and 12 months mortality were recordedalong with the outcome in diagnostic and organ system supportsubgroups. Intensive care, hospital, 6 month and 12 month mortalityrates were 58, 71, 78 and 81%. Results. Hospital mortality in the sepsis/multiorgan failuregroup was 88%. Sixty-nine per cent of patients who were ventilatedbut required no other organ support survived to hospital discharge.However, the requirement for any other organ support, or a raisedcreatinine (>120 µmol litre^–1) in the first 24h, reduced the hospital survival to <15%. In those patientsrequiring acute renal replacement therapy, the hospital mortalitywas 94%. Conclusion. Decompensated ALD requiring intensive care admissionis associated with a high hospital mortality and considerationshould be given to the futility of escalating organ supportmeasures, particularly when renal replacement therapy is required.     

Undergraduate education on the intensive care unit

The Intercollegiate Board for Training in Intensive Care Medicinehas recommended that medical students should be exposed to aperiod of structured training in intensive care.¹ The importanceof training in the management of the critically ill patienthas also been emphasized by the General Medical Council.² Thecurrent state of medical student training in intensive careis not known. We performed a questionnaire study to investigatethe level of undergraduate experience of intensive care nationally. A questionnaire was sent to the director of each intensive careunit (ICU).³ The questionnaire asked about the number of medicalstudents attached to the ICU, the duration of the attachments,teaching and assessment procedures and satisfaction with thepresent situation. It also asked about potential problems experiencedby medical students. Another questionnaire was piloted to groupsof first and fourth year medical students. This questionnaireasked about the usefulness of undergraduate intensive care training,the students experience of such training and possible problems. The response rate for the ICU questionnaire was 155/267 (58%).Medical students were attached to 79 (51%) of responding ICUs,26 (33%) of attachments were for one day and 73 (92%) for amonth or less. Of the units offering attachments, 50 (63%) receive10 students or fewer each year and 15 (19%) receive more than25 students annually. One unit offered a first year attachment;53 (68%) offered final year attachments. During the attachments,57 (72%) of units gave up to 5 h of teaching each week and 42(43%) assessed the students during the module, usually by awritten report. Of the respondents 39 (49%) were dissatisfiedwith the level of intensive care experience gained by studentsand most thought intensive care was a vital part of undergraduatetraining. The technical atmosphere and clinical complexity ofintensive care were thought to be potential problems by 40%and 36% of respondents. Twenty-five first year and 25 fourthyear medical students completed the student questionnaire. Ofthese, 46 (92%) thought it should be possible to spend sometime on the ICU before graduating and 47 (94%) thought the thirdyear the most appropriate time. More students (41 (82%)) believedthat the technology and complexity of intensive care were importantproblems in intensive care teaching. Few medical students are exposed to intensive care during theirundergraduate training and then for only a short time. Thereis dissatisfaction from students and intensivists with the currentlevel of undergraduate intensive care experience. The technologyof intensive care and the complexity of the clinical problemsare perceived as problems by students but not by clinicians.The ICU is a valuable resource for training knowledgeable, skilfuldoctors; at present that resource is underused.