Obstetric admissions and outcomes in an intensive care unit in Malawi

BackgroundDespite international commitment to Millennium Development Goal 5, maternal mortality remains high in low- and middle-income countries (LMICs) of sub-Saharan Africa. This is in part due to infrastructure gaps, including availability of intensive care units (ICUs). We sought to use obstetric ICU utilization as a marker of severe maternal morbidity and provide an initial characterization of its relationship with in-hospital mortality.MethodsA prospective observational cohort study of all obstetric subjects admitted to the ICU of Kamuzu Central Hospital in Malawi from September 2016 to March 2018. We reviewed charts at the time of ICU admission to assess the indication for admission, clinical characteristics and laboratory values. Subjects were followed until death or discharge. The primary outcome was in-hospital mortality.ResultsOne-hundred-and-five obstetric patients were admitted to the study ICU (23% of all admissions). The median age was 26 years. The majority (79%) had undergone recent surgery; 40 (52%) an abdominal postnatal or cesarean hysterectomy and 31 (40%) a cesarean delivery without hysterectomy. Ninety-five percent required mechanical ventilation and 48% required vasopressors. Overall in-hospital mortality was 49%.ConclusionsThe proportion of obstetric subjects admitted to the ICU in Malawi is nearly 1 in 4, which exceeds that found in high-income countries by orders of magnitude. Intensive care unit admission was associated with high mortality in this population. Investments in improving infrastructure and care gaps may include addressing available ICU bed and blood-banking needs, and increasing the number of providers trained in managing critical illness among obstetric patients.     

Alcohol-associated admissions to an adult intensive care unit: an audit

BACKGROUND AND OBJECTIVE: Excessive alcohol consumption is a major cause for premature death and preventable ill health in the whole population. We set out to audit admissions to the intensive care unit (ICU) of our large teaching hospital with respect to alcohol-related admissions. METHODS: A prospective audit was conducted into alcohol-associated admissions to our university hospital adult ICU over 12 months. The following data were collected for each patient admitted: age, gender, diagnosis and amount of alcohol consumption, APACHE II score, and the probability of death. RESULTS: Patients with definite alcohol consumption constituted 39.1% (124 patients) of all admissions (317 patients) to the ICU. In Group 1 (89 patients), the admission was directly associated with alcohol consumption, which included heavy alcohol consumption. Group 2 (35 patients) consisted of 'social drinkers'; and Group 3 was composed of patients who denied any alcohol intake. Group 1 had a high median APACHE II score of 19 (range 4-35) and a significantly higher mortality rate (41.6%) than Group 3 (18.4%, P < 0.001) or the entire sample studied (23.7%, P < 0.001). The results also demonstrated an incidence of pneumonia of 29.2% (26 patients) in alcohol-associated admissions compared with 22.8% (eight patients) in Group 2 and 21.8% (19 patients) in Group 3. Trauma admissions amounted to 11.4% of the patients studied (24/211 patients), 17 (70.8%) of whom were directly associated with alcohol and it included 11 pedestrians. CONCLUSIONS: Alcohol may play a major role in the admission and mortality of ICU patients. Further investigations are warranted because our sample size is so small.     

Pregnancy-related admissions to the intensive care unit

We conducted a retrospective review of obstetric patients admitted to the intensive care unit at Al-Ain hospital during period January 1(st) 1997 to December 31(st) 2002, in order to identify the indications for admission and the outcome. A total of 60 patients were admitted during the six years. The frequency of admission was 2.6 per 1000 deliveries and obstetric patients represented 2.4% of all ICU admissions. Admission was planned in 11 patients (18%) and unplanned in 49 (82%). The mean (+/-SD) duration of stay in ICU was 1.6+/-1.5 days. The leading indications for admission were haemorrhage (28.4%) and preeclampsia/eclampsia (25%). Of the 60 admissions, 47 (78.4%) followed surgery. The mean APACHE II score was 5.0+/-3.0. Twenty-two patients (37%) had blood transfusions, and only two (3.3%) required ventilation. Of the 60 patients only 28 (46.7%) were deemed to have severe illness necessitating intensive care; the remaining 32 patients were suitable for high dependency care. The mean APACHE II score and duration of stay were significantly higher in these patients. There were two deaths, representing 3.3% of obstetric intensive care unit admissions. Our findings highlight the need for establishing a high dependency unit to avoid unnecessary admission to the intensive care unit and to ensure proper management.     

Paediatric admissions to a district general hospital intensive care unit

The characteristics of all the paediatric admissions made to a district general hospital over a three-year period were analysed in this study. Paediatric admissions averaged 23 per year (10% of the total admissions to the unit over that time). The mean age was six years, median age was four years. Sixty-two per cent were medical admissions and 38% surgical. Forty-seven per cent of the surgical admissions involved head injuries. Seventy-four per cent of medical admissions were directly related to upper and lower airway problems. Mean total admission time was six days, with a median of two days. Fifty-nine per cent (40) of all cases required intubation for a mean period of five days (median = three days). All cases were PRISM scored (Pollack, Ruttimann & Getson 1988). The mean score was 8. Ninety-four percent of admissions surviving to go home. There were a total of four deaths over the three-year period. The PRISM scores of those who died had a mean of 30, which was significantly different (P < 0.05) from the survivors who had a mean PRISM score of six and a median of four. The organs of one of the nonsurvivors were transplanted. Currently there is considerable interest in the feasibility of transferring all paediatric intensive care patients to a regional centre, the consequences of such a policy must be carefully assessed if its implementation is to be a success.     

Survey of alarms in an intensive therapy unit

The origin and frequency of alarm soundings in a general purpose intensive therapy unit were recorded by the nursing staff for 3 weeks. Only eight out of a total of 1455 soundings indicated potentially life threatening problems. There were many false alarms from the monitoring system and the infusion rate pump. The overall frequency of soundings varied little by day or night. There is a need for a graded system of alarms to reflect the priority of the disturbance detected.     

Mortality amongst multiple trauma patients admitted to an intensive therapy unit

A retrospective review of 428 severely injured patients admitted to an intensive therapy unit between 1969 and 1982 was performed. The patients' primary injuries were assessed using the injury severity score (ISS), and subsequent complications using the complications impact index and sepsis score. Between 1969 and 1980 mortality fluctuated between 19% and 29% but rose to 47% (p less than 0.05) during 1981-82 in spite of an unchanged ISS. The increased mortality was confined to ventilated patients surviving more than 5 days from injury and was associated with multiple organ failure and severe infection. The rapid and sustained increase in mortality could not be explained by any obvious change in severity of injury or referral pattern. The only deliberate change in management related to the combination of analgesic/sedative drugs used in ventilated patients. During 1979 to 1982 mortality was 28% in patients given morphine with or without benzodiazepines and 77% in those given morphine and etomidate (p less than 0.0005). After discontinuation of the latter regimen (May 1983) and resumption of the former analgesic/sedative combination, mortality fell to 25% (p less than 0.005). Possible mechanisms leading to increased mortality include adrenocortical insufficiency or depth of anaesthesia.     

The Guillain-Barré syndrome. A review of admissions to an intensive care unit over 8 years

Forty-four patients with a diagnosis of Guillain-Barré syndrome were admitted to the Intensive Care Unit at Baragwanath Hospital, Johannesburg, between January 1975 and December 1982. Of these patients 7 were found to have other diseases with similar features, and they were excluded from the study, leaving 37 patients; 2 patients were admitted twice. An unexpected finding was that 21 patients (56,8%) were less than 10 years of age. Respiratory failure was present on admission in 15 cases (38,5% of the 39 admissions). Treatment was mostly supportive in nature and included assisted ventilation. Most morbidity involved the respiratory system. The high mortality (8 patients (21,6%) died) was probably due to the severe nature of the disease in these cases.     

Maternal and neonatal characteristics in obstetric intensive care unit admissions

BackgroundThe objective of this study was to evaluate the course of pregnancy and delivery of obstetric patients admitted for intensive care, and determine the health status of their infants.MethodsThis was a retrospective register-based study. Four university hospitals in Finland participated. Obstetric patients admitted to the intensive care unit in any trimester of pregnancy, during delivery or up to 42 days post partum were identified from clinical information systems over a five-year study period. Parturient and infant data were collected from the Medical Birth Register.ResultsDuring the study period (2007–2011), 283 obstetric patients were identified from the clinical information system. The most common reason for admission was hypertensive complications (58%), followed by obstetric haemorrhage (25.1%). Advanced maternal age, nulliparity and multiple pregnancies were associated with obstetric intensive care unit admissions. Of patients admitted to intensive care, 68.9% delivered by unscheduled caesarean section. Nearly 60% of neonates were born preterm, 56.1% needed treatment in a neonatal intensive care unit or an observation unit and 4.6% died within one week.ConclusionAdvanced maternal age, nulliparity and multiple pregnancy were more common among intensive care unit-admitted women than in the general obstetric population. The main causes for admission were hypertensive complications and obstetric haemorrhage. Compared with the general obstetric population, neonates of intensive care unit-admitted mothers were eight times more likely to require treatment on a neonatal ward and their risk of neonatal death was also eight times greater.     

Audit of intensive care unit admissions from the operating room

An audit of 265 intensive care unit (ICU) admissions from the operating room was performed for the year 1991. In a quality assurance exercise we identified 34 unanticipated ICU admissions (UIAs) by a retrospective peer review of the medical charts. Of these UIAs, 16 were deemed predictable and seven preventable. Five of the seven potentially preventable UIAs were judged to have had inappropriate intravenous fluid management. This has prompted changes in our education programme. In an assessment of our resource management, we evaluated prospectively collected data on the Apache II scores on the day of admission, the incidence of ICU-specific interventions, length of stay in ICU, and outcomes. ICU-specific interventions were not initially required in 36% of admissions and these patients had a low risk (1.1%) of eventually requiring ICU-specific interventions. In comparison with patients requiring ICU-specific interventions, they had lower Apache II scores (10.2 vs 13.1), shorter ICU stays (medians of one vs two days), lower ICU mortality (0 vs 8.2%), P < 0.05, but hospital mortality was not different (7.4 vs 15.3%). This audit has prompted re-organisation of our intensive care services, so that patients not requiring ICU-specific interventions will be managed in an intermediate care area with nurse.patient ratios of 1:3 or 4, in comparison with 1:1 or 2 ratios in the intensive care area.     

Implementation of a standardized handoff protocol for post-operative admissions to the surgical intensive care unit

Background

The transfer of critically ill patients from the operating room (OR) to the surgical intensive care unit (SICU) involves handoffs between multiple providers. Incomplete handoffs lead to poor communication, a major contributor to sentinel events. Our aim was to determine whether handoff standardization led to improvements in caregiver involvement and communication.

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study

BACKGROUND: Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol. METHODS: A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied. RESULTS: The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions. CONCLUSION: ICU admission is very often related to long-term chronic and/or occasional alcohol use.     

Cocaine‐related admissions to an intensive care unit: a five‐year study of incidence and outcomes

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18‐bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine‐related cases, measuring hospital mortality and long‐term survival in early 2009. Cocaine‐related admissions increased from around one annually in 2003–05 to 10 in 2007. Their median (IQR [range]) age was 25 (21–35 [17–47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11–27 [5–36]) and length of intensive care stay was 5 (3–9 [1–16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow‐up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.     

Diagnostics and therapy for invasive fungal infections in an intensive care unit

Invasive fungal infections are associated with a high mortality and have been increasing in incidence over the last few decades. Candidemia and, less commonly, invasive pulmonary aspergillosis are the most relevant fungal infections in critical care medicine. Risk factors for systemic Candida infections are the use of broad-spectrum antibiotics, a prolonged stay in an intensive care unit and gastrointestinal injury or surgery. Invasive aspergillosis usually occurs in immunocompromised patients. The diagnosis of invasive fungal infections remains challenging. The therapeutic spectrum includes fluconazol, conventional and liposomal amphotericin B, and the recently introduced agents caspofungin and voriconazol. For rational and cost-effective use, the clinician requires precise knowledge of the indications and limitations of these agents. This review focuses on the diagnostic and therapeutic options in severe Candida infections and invasive aspergillosis.