Nutrition in patients with burn injuries in the intensive care unit

Authors discuss the choices of nutritional support in patient after severe burn injury during the last three decades. Severe burn injury presents one of the most critical states of starvation under a severe stress to the organism. Timely and appropriate metabolic intervention can positively influence the hypermetabolism, which is a common reaction after an injury. Burn injury causes a long-term reaction with a great risk of multiple organ dysfunction (requirement to perform repeated dressing changes under general anesthesia, repeated surgeries, and infections). Incorporation of a nutritional support is based on the knowledge of pathophysiology and metabolic response to injury, and is influenced by choice of nutrition substrates and by possibility of its administration.     

The role of the intensive care unit in a district hospital

The evolution of an intensive care facility in a District General Hospital is recorded. Optimum use of the Unit was achieved by accepting both critically ill and high dependency care patients. This has been of benefit to both the staff and patients and may be reflected in the falling mortality of the critically ill surgical patient. High dependency care patients now only stay 1.3 days and there has been no mortality. In view of the ageing population and the cost of such units, this dual role in the District General Hospital Intensive Care Unit appears justified.     

Cryotherapy for retinopathy of prematurity in a regional neonatal intensive care unit.

Ninety-six low birth-weight premature infants at risk of retinopathy of prematurity (ROP) were screened over a 25-month period, yielding 30 eyes of 15 infants with 'treatable' disease. The response and complications of cryotherapy were prospectively evaluated in these infants over a 3-24-month period. Six eyes of three infants progressed to cicatricial disease despite treatment. One infant developed angle closure glaucoma but neither eye showed cicatricial disease. In 24 eyes of 12 infants regression of active ROP was observed after treatment. The local and systemic complications associated with cryotherapy are discussed.     

Experiences with head injuries in a regional neurosurgical unit.

A review of all patients with major head injuries transferred to a regional neurosurgical unit for the years 1975 and 1976 has been carried out for comparison with the total number of patients with head injury admitted to district general hospitals of the region. Fifty-four per cent of patients admitted to the neurosurgical unit have resumed their old occupation and 20 per cent died. The significance of these figures is discussed, particularly in the light of the need for a more comprehensive policy for treating head injuries within the United Kingdom.     

Ruptured abdominal aortic aneurysm--outcome in a community teaching hospital intensive care unit.

Ruptured abdominal aortic aneurysm (RAAA) is a surgical emergency associated with a high mortality often requiring postoperative intensive care. Our objectives were to assess the outcome of RAAA management in a nontertiary community hospital intensive care unit (ICU) and to compare this with historical data from tertiary hospitals. We also sought to identify variables related to outcome and evaluate the potential of an organ failure score to identify patients at increased risk of death. The study was a retrospective chart review of patients with RAAA over 11 years (1986-1996 inclusive) at Manly District Hospital, a 210 bed community teaching hospital with eight intensive care beds. Forty patients were identified in the study period as having been admitted to ICU after RAAA surgery. There was an overall hospital mortality rate of 47.5% and intensive care mortality rate of 42.5% for successfully operated RAAA. Five variables were significantly different between survivors and non-survivors. These were age, total amount of blood products required, duration of operation, development of hypotension (systolic blood pressure < 90 mmHg) in ICU postoperatively, and APACHE II score at Day 1 ICU. A trend was also found between mortality rate and the number of failed systems after 48 hours intensive care stay. Mortality for a patient with zero failed systems was 38%, one failed system 42%, two 58% and three 67%. Based on these results, management of RAAA in a non-tertiary setting appears appropriate with postoperative care occurring in an ICU where there is adequate equipment and medical and nursing staff experienced in the care of complex critical illness.     

Evaluation of an intensive care unit in a teaching hospital in Saudi Arabia.

Intensive Care Units (ICU) in general hospitals have become a standard requirement in tertiary care centres. However, the appropriateness of their use is not widely known. We have used the Therapeutic Intervention Scoring System (TISS) to evaluate a multidisciplinary ICU in a teaching hospital in Saudi Arabia. The average occupancy rate was 79%, the nurse: patient ratio was 1:1.4, duration of stay 4.1 +/- 3.5 days, and mortality was 1.4%. The distribution of severity of illness was as follows: Classes I & II, 82%, and Classes III & IV, 18%. The average TISS points were: daily per patient 15.1 +/- 2.7 (range 11.5-21.7), total per day 125.6 +/- 38.2 (range 35-211), and patient points per nurse was 21.1. We conclude that, although less than 20% of patients required unique ICU services, the use of our ICU was appropriate to the current medical and manpower training needs of the community it was designed to serve, but the basis of nurses' complaints of overwork remains to be determined.     

Treatment of seizures in the neurologic intensive care unit

Opinion statement Seizures occur more often in the neurologic intensive care unit (NICU) than in general or other specialty ICUs, in part because of the patient population, but also due to the enhanced neurologic monitoring undertaken in such units. Especially important for the detection of seizures is the use of specialty trained personnel and the use of continuous electroencephalographic monitoring. The etiology of seizures often can be categorized either by primary brain pathology, at macro-or microscopic level, or by physiologic derangements of critical care illness, such as toxic or metabolic abnormalities. Particular etiologies at risk for seizures include hemorrhagic stroke and traumatic brain injury. The use of prophylactic antiepileptic drug administration remains controversial. If seizures occur, patients are typically treated with parenteral antiepileptic drugs. The duration of treatment is unclear in most situations, but data support limited treatment for early-onset ICU seizures that are easily controlled, with treatment not extending beyond a few weeks or a month. Late seizures, which occur more than 2 weeks after the insult, have a more ominous correlative risk for subsequent epilepsy and should be treated for extended periods of time or indefinitely. Electrolyte and glucose abnormalities, when corrected, usually lead to seizure control. This review concludes by examining the treatment algorithms for simple seizures and status epilepticus and the role newer antiepileptic use can play in the NICU.     

Treatment of injuries of the heart and pericardium in a regional hospital]

Wounds of the heart and pericardium were observed in 19 patients. Four patients died. The main causes of death were acute blood loss, shock, tamponade of the heart. Urgent operations are indicated to all the patients with wounds in the cardiac area. The outcome of the surgery is dependent on the rapid and efficient operation and adequate blood supply.     

The early assessment and intensive care unit management of patients with severe traumatic brain and spinal cord injuries

The assessment and management of neurotrauma have progressed significantly over the past several years. Improved understanding of the physiology of injured neural tissue and advances in technology have refined the approach to the care of patients suffering neurologic injury. Evidence-based clinical management guidelines, such as those developed by the Brain Trauma Foundation and the American Association of Neurological Surgeons, for the management of traumatic brain injury have been introduced to standardize certain aspects of care. The ongoing evolution of critical care also has had a significant impact on the care of patients suffering from neurotrauma. This article reviews some current issues related to the diagnosis and management of traumatic brain injury and spinal cord injury as we head into the next millennium.     

An intensive care unit in a rural area.

Factors that governed the setting up of a multipurpose, temporary Intensive Care Unit of six beds, in a remote area of Malaysia and the experience of operating it for more than two and a half years are outlined.     

Nursing audit in a neonatal intensive care unit.

The amount and quality of work conducted by nurses in a neonatal intensive care unit was assessed by analysing records of observations, investigations and treatment. Work had been standardised as much as possible to ensure continuity and to prevent mishaps. Seventy-seven infants were treated over a 5-month period and 6 died of causes unrelated to patient care. Nursing staff were responsible for all observations and for the collection of most specimens for investigations. They also performed 20% of emergency procedures, such as endotracheal intubation and the insertion of venous catheters. The only errors which could be detected were omissions in observations (2.9%), nursing procedures (2.9%), and drug doses (1.2%). The nurse-to-baby ratio of 1:3 was adequate for patient care but not for other recognised functions of an intensive care unit such as education programmes.     

Treatment of acute self-poisoning in a respiratory intensive care unit. A 5-year review

A study of 103 cases of drug-related suicide attempts admitted to the Respiratory Intensive Care Unit, Groote Schuur Hospital, over a 5-year period (1980-1984) was carried out. This group constituted 4.8% of all patients admitted to this hospital with acute self-poisoning. The majority of patients made an uneventful recovery (survival rate 91.7%). No association was found between initial admission status and ultimate recovery. Haemoperfusion was useful in treating patients with severe barbiturate poisoning.     

Occupancy of a teaching hospital adult intensive care unit by high dependency patients

We assessed the hourly occupancy of our intensive care unit by high dependency patients over an 8-week period using the criteria established by the Working Group on Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units published by the National Health Service Executive. High dependency patients accounted for 1914 bed hours (21.6%) out of a potential available total of 8880 hours. Measurement of Therapeutic Intervention Scoring System points and Acute Physiology and Chronic Health Evaluation II scores confirmed that categorising patients according to the new guidelines produced significantly different populations of patients. Mean (standard deviation) Therapeutic Intervention Scoring System points for intensive care status patients were 38.57 (10.40) compared to 21.66 (5.98) points for high dependency status patients (p < 0.001). Median (range) Acute Physiology and Chronic Health Evaluation II score for intensive care status patients was 16 (1–45) compared to 11 (1–27) for high dependency status patients (p < 0.0001). Calculating bed occupancy with different definitions for the whole of our intensive care unit population during the 8 weeks revealed a range of occupancies between 85.3% and 107.3%. We recommend that intensive care unit bed occupancy should be calculated in a standard manner nationally to allow comparison between units. We suggest that hourly occupancy be adopted as the universal method.