Acute methanol intoxication: a survey of patients requiring intensive therapy

A survey of patients suffering from severe acute methanol intoxication who required admission to an Intensive Therapy Unit was carried out. The clinical features of 25 patients admitted during an 18-month period are presented, together with case histories of the two patients most severely affected. The investigation and management of such patients are discussed.     

Abbreviated laparotomy in patients with hemorrhagic shock

Five cases of severe hemorrhagic shock of abdominal origin treated with abbreviated laparotomy due to the onset of hypothermia, acidosis and consumption coagulopathy are described. The abdomen was temporarily closed and the patients were transferred to these Intensive Therapy Unit for the treatment correction of these disorders. Patients were then re-operated on 30 hours after the reestablishment of vital functions. Clinical complications of hemorrhagic shock, in which the "Abbreviated Laparotomy" technique is applicable, are presented.     

Fatores de risco para mortalidade após hemorragia subaracnoidea: estudo observacional retrospectivo

Background and objectivesSubarachnoid haemorrhage is an important cause of morbidity and mortality. The aim of the study was to determine predictors of mortality among patients with subarachnoid hemorrhage hospitalized in an Intensive Care Unit.MethodsThis is a retrospective study of patients with subarachnoid hemorrhage admitted to the Intensive Care Unit of our institution during a 7 year period (2009–2015). Data were collected from the Intensive Care Unit computerized database and the patients’ chart reviews.ResultsWe included in the study 107 patients with subarachnoid haemorrhage. A ruptured aneurysm was the cause of subarachnoid haemorrhage in 76 (71%) patients. The overall mortality was 40% (43 patients), and was significantly associated with septic shock, midline shift on CT scan, inter‐hospital transfer, aspiration pneumonia and hypernatraemia during the first 72 hours of Intensive Care Unit stay. Multivariate analysis of patients with subarachnoid hemorrhage following an aneurysm rupture revealed that mortality was significantly associated with septic shock and hypernatremia during the first 72 hours of Intensive Care Unit stay, while early treatment of aneurysm (clipping or endovascular coiling) within the first 72 hours was identified as a predictor of a good prognosis.ConclusionsTransferred patients with subarachnoid haemorrhage had lower survival rates. Septic shock and hypernatraemia were important complications among critically ill patients with subarachnoid haemorrhage and were associated increased mortality.     

Iatrogenic anaemia? A survey of venesection in patients in the Intensive Therapy Unit

In 30 consecutive patients admitted to the Intensive Therapy Unit, the volume of blood taken for investigations was recorded. Results were available for 26 patients. Total venesection volume averaged 336 ml. Venesection volume averaged 55.7 ml/day after the first 24 hours. The mean haemoglobin on admission was 11.5 g/d litre. Blood loss was related to both APACHE score and length of stay (APACHE.day), to the presence of arterial and central venous catheters, and to the need for mechanical ventilation. Iatrogenic blood loss of this magnitude will cause anaemia if it continues.     

Colloid solutions in the critically ill

All patients admitted to an Intensive Care Unit were randomised to receive all volume replacement fluid as either human albumin solution or a synthetic colloid. A total of 475 patients were admitted during the study period. Patients' age, sex, APACHE score and calculated risk of death were assessed on admission. Outcome was assessed as length of Intensive Care stay and mortality. There was no difference between the groups. Subgroups of patients with APACHE score greater than 10, calculated risk of death greater than 50% and length of stay greater than 5 days were also evaluated but not significant differences were found between treatment groups. The use of albumin rather than 3.5% polygeline for volume replacement in the Intensive Care Unit has no influence on outcome.     

重型颅脑外伤患者术后早期营养支持策略的选择与疗效分析

目的 研究三种不同早期营养支持方案下重型颅脑外伤患者术后营养状况及短期预后的差异.方法 回顾性分析2014年7月-2016年7月苏北人民医院神经外科重症监护室收治的60例重型颅脑外伤术后患者,依据不同营养支持方案分为早期联合营养组、早期肠内营养组和早期肠外营养组.记录三组患者治疗前的基础临床特征、治疗后两周内的营养数据以及神经外科重症监护室住院时间、并发症情况和GCS评分.结果 早期营养支持中,早期联合营养组患者空腹血糖、血清前白蛋白、血清总蛋白、全血血红蛋白、C-反应蛋白分别为(5.74±0.64)mmol/L、(203.80±10.45) mg/L、(61.99±1.34) g/L、(114.53 ± 2.69) g/L、(0.37±0.06) mg/dl,以上数据改善情况均优于早期肠内营养组及早期肠外营养组.早期联合营养组神经外科重症监护室住院时间(11.6±0.42)d明显低于早期肠内营养组(13.20±0.42)d及早期肠外营养组(14.65±0.42)d.早期联合营养组并发症发病率最低.早期联合营养组GCS评分(11.40±1.60)分改善最显著,差异均具有统计学意义(P＜0.05).结论 重型颅脑外伤术后早期施行肠内外联合营养治疗能显著促进患者营养指标提升,同时降低并发症发病率,缩短神经外科重症监护室住院时间,减轻昏迷程度,值得临床推广.     

Cause of death after critical illness

This study reports the causes of death after discharge following treatment of life-threatening illness on an Intensive Therapy Unit. Details of survivors discharged between June 1985 and December 1988 were sent to the Registrar General for Scotland who subsequently issued copies of death certificates of those patients who had died between discharge and 1 January 1990. The results show that the commonest causes of death after discharge were malignancy and respiratory failure, although there is wide variation in the post-discharge mortality rates for different diagnostic categories. The admission diagnoses were identical to, or contributed to, the causes of death in 64% of patients who died after discharge. Eighty-five percent of patients who died from the same condition which prompted admission did so within a year following discharge, but after 2 years no deaths were attributed to the admission diagnosis.     

Successful early voriconazole treatment of Aspergillus infection in two non immunocompromised patients in Intensive Care Unit

We report two cases of respiratory Aspergillus infection that occurred in patients admitted to the Intensive Care Unit of a teaching hospital during renovation works and treated with new triazole voriconazole (Vfend). The first patient was affected with cerebral hemorrhage, the second with polytrauma and both developed Aspergillus Pneumonia during their ICU stay. Bronchoalveolar lavage, dosage with anti-Aspergillus antibodies, antigen measurements and galactomannan research with Sanofi Platelia were performed. Therapy was carried out with voriconazole for 12 days. Chest X-ray and laboratory tests showed complete resolution after 12 days of therapy; clinical symptoms were negative after 4 days. Aspergillus infection can be observed frequently in non-immunocompromised patients during ward renovation or in hospitals near building areas. Since treatment is often unsuccessful, we preferred to immediately employ new agents to reduce the impact of this disease.     

Deep sternal wound infection following cardiac surgery: A comparison of the monolateral with the bilateral pectoralis major flaps

Deep sternal wound infections are a serious complication following sternotomy for cardiothoracic surgery. “Conventional” treatment provides debridement and secondary closure or closed catheter irrigation. The combination of the Negative Pressure Therapy with flap coverages is an accepted technique and one or both Pectoralis Major muscles could be chosen. A multistep protocol was adopted. One hundred and sixty seven patients were treated with the combination of Negative Pressure Therapy with the Pectoralis Major muscle flap: 86 monolateral flap and 81 bilateral flap reconstruction. The main complications (hematoma, seroma, dehiscence, and re‐infection), the need for re‐intervention, mortality rates, Intensive Care Unit, and hospitalisation time were assessed. The mono‐pectoralis group had fewer complications and need for revision, with a shorter hospital stay. A statistically significant difference emerged for the hematoma rate (P = .0079). Monolateral flap should to be preferred because with the same coverage effectiveness, it guarantees the saving of controlateral muscle with its functionality and the possibility of its use in case of failure. Furthermore, as the technique is less invasive, it can be reserved for more fragile patients.     

Time-dependent error in the APACHE II scoring system.

Using the APACHE II scoring system, the risk of death was calculated for 189 patients in the Wanganui Intensive Care Unit and 194 patients in the Harare Intensive Care Unit. Using tables of actual and predicted outcome, the predictive power of the system was compared in patients grouped according to the length of time that they spent in the ICU. The predictive error increased from 15% in those patients staying less than six days, to 38% in those staying six days or more (P less than 0.01). The predictive accuracy of the APACHE II system appeared to decrease with the length of time the patient stayed in the Intensive Care Unit.     

Glycemic control in critically ill patients: What to do post NICE-SUGAR?

Until recently, stress hyperglycemia was considered to be a beneficial adaptive response, with raised blood glucose providing a ready source of fuel for the brain, skeletal muscle, heart and other vital organs at a time of increased metabolic demand. Following the Leuven Intensive Insulin Therapy Trial in 2001, tight glycemic control became rapidly adopted as the standard of care in intensive care units (ICU's) throughout the world. However, four randomized controlled studies and the recently published NICE-SUGAR study have subsequently been unable to replicate the findings of the Leuven Intensive Insulin Therapy Trial. This paper offers an explanation for these discordant findings, and provides a practical approach to glucose control in the ICU.     

Obstetric admissions to an intensive therapy unit

Complications of pregnancy may necessitate admission to an Intensive Therapy Unit (ITU). All obstetric patients admitted to ITU were reviewed in order to assess whether these admissions could have been predicted and to determine the place of intensive care compared with high dependency nursing. Case notes of 122 women from a total group of 144 women admitted to an ITU of an inner-city hospital from 1989-1993 were reviewed retrospectively. The majority of women (67%) had no pre-existing medical or obstetric history. The major indications for admission were hypertensive disease of pregnancy (66%) and haemorrhage (19%); 79% followed caesarean section and 40% required ventilatory support. The perinatal mortality rate was 6% and there were three maternal deaths. The need for admission to ITU was unpredictable in two-thirds of the cases. Many of the women evaluated in this review were ineligible for high dependency care and required full ITU facilities, both of which will always be needed to deal with serious complications of pregnancy.     

Transfer of the critically ill obstetric patient: experience of a specialist team and guidelines for the non-specialist

Transfer of the critically ill obstetric patient between hospitals is increasingly common. The specialist transfer team based at the Western Infirmary Intensive Therapy Unit, Glasgow has transported 60 such patients in the years 1985-1994. Monitoring was by direct arterial pressure measurement in 56 patients and central venous pressure measurement in 45. Forty-one patients were mechanically ventilated in transit. There were no deaths in transit but 3 patients died later in intensive care. The majority of patients had pregnancy induced hypertension or had suffered a post partum haemorrhage. A clinical impression that these two groups had different treatment requirements and outcomes was not substantiated. We conclude that the transfer of even the sickest obstetric patient is feasible and safe and suggest guidelines to non-specialists for the management of these patients before and during interhospital transfer.     

Operation Bali assist--the Royal Darwin Hospital Intensive Care Unit

On October 12, 2002 the Bali bombing resulted in 62 severely injured patients being evacuated to Royal Darwin Hospital. This paper describes the planning and execution of the Intensive Care Unit disaster plan in the wake of the Bali bombing. There were a total of 20 patients from the Bali blast admitted to the Intensive Care Unit. The disaster operation was successful with all patients admitted, resuscitated, emergency treatment performed and then evacuated to interstate burns units in a timely and efficient manner.     

A study of 13 cases of near-hanging presenting to an Accident and Emergency Department

This paper reports 13 cases of near-hanging presenting to the Accident and Emergency (A + E) Department of a District General Hospital over a 52-month period. The purpose of the study was to analyse the epidemiology, methods, outcomes and complications of near-hanging. There were 13 cases in the study period, 12 of whom were male and 1 female. The mean age was 31 years. The most common method used was rope (five cases). The estimated mean duration of hanging was 5 min. Height of fall data was poorly recorded but only one fall was recorded as being more than 3 ft. Many had a very poor clinical picture on arrival of the ambulance crews: seven had a Glasgow Coma Score (GCS) of less than or equal to 8 on scene, of which five required intubation. Five patients required ventilation and a period of treatment on the Intensive Therapy Unit (ITU). There were no cervical spine (C-spine) injuries, nor neurological complications. There were two incidences of aspiration pneumonia. All of the patients made a full recovery. It is concluded that patients presenting with this injury go on to make a full recovery, despite an often dismal initial clinical picture.     

VAC therapy with long term continuous saline infusion for secondary septic peritonitis: A new strategy for the reduction of perioperative risks?

BackgroundThe management of a septic peritonitis open abdomen is a serious problem for clinicians. Open surgery is associated with several complications such as bleeding and perforation of the bowel.Case presentationThe authors report a case of a 59-years-old female who underwent a sigmoid resection with an latero-terminal (L-T) anastomosis for the perforation of a diverticulum. After a few days the patients developed a new widespread peritonitis. At the emergency re-laparotomy, surgeons found dehiscence of the posterior wall of the anastomosis with fecal contamination. At admission in ICU (Intensive Care Unit) the patient had open abdomen with dehiscence of cutaneous and subcutaneous layers.ConclusionConservative therapy with antibiotic therapy and use of the Vacuum-Assisted Closure^® (VAC) Therapy with a long term continuous saline infusion led to the resolution of the septic shock and to the wound healing.     

ARDS in MOFS (multiple organ failure syndrome). How to direct the therapy? A case report of MOFS in AIDS

A young AIDS patient was admitted to the Intensive Therapy ward of our hospital with ARDS. The case raised the question of how medical and nursing personnel should face the problem of "suitable treatment for a terminally ill patient". Therapy was based on invasive methods such as mechanical ventilation and the insertion of catheters to monitor vital parameters. The evolution of ARDS in MOFS revealed the difficulty of sustaining vital parameters and avoiding pluriorganic damage.     

A comparison of APACHE II and a clinical sickness score

The aim of this study was to compare the predictive power of a simple illness severity score (Clinical Sickness Score) to that of APACHE II in a District General Hospital intensive therapy unit. A prospective comparison was carried out on 97 consecutive adult patients whose severity of illness was scored one hour after admission using both the Clinical Sickness Score and APACHE II. Intensive Therapy Unit and hospital outcomes were recorded for each patient. The Clinical Sickness Score and APACHE II identified survivors and nonsurvivors with similar power (p less than 0.001). There was a highly significant correlation between the two scoring systems for hospital survivors and nonsurvivors together (r = 0.5418, r2 = 0.28, p = less than 0.0001) and for hospital survivors alone (r = 0.6102, r2 = 0.37, p = 0.0001). Correlation for hospital nonsurvivors was not significant (r = 0.1629, r2 = 0.027, p = 0.3134). The positive predictive values of APACHE II were between 5% and 10% more sensitive than the Clinical Sickness Score for hospital outcome. Admission Clinical Sickness Score and APACHE II scores had similar predictive power in this study.     

Antibioticotherapy based on statistics in intensive therapy

The authors present the epidemiological data concerning nosocomial infections in their Intensive Care Unit, and discuss an antibiotic strategy statistically oriented by these data. In their experience, treatment based on statistical criteria, brought to a reduction in antibiotic consumption with particular regard to broad-spectrum antibiotics, and to a decrease in individual budget.     

Treatment of severe diabetic acidosis with tris-hydroxymethyl aminomethane in a thirteen-year-old child

Diabetic ketoacidosis is a severe complication of type I diabetes. A 13-year-old female (40 kg) patient was admitted to our Intensive Care Unit with severe metabolic acidosis (pH: 6.8), hyperglycemia (835 mg/dL) and coma. Her hemodynamic conditions were unstable and, even though a large amount of plasma expanders, crystalloids, and inotropic support were supplied, the patient went into cardiac arrest in the first hour of treatment. After resuscitation, a better hemodynamic balance was achieved and metabolic acidosis was treated with fluid replacement therapy, continuous insulin infusion, and Tris-hydroxymethyl aminomethane (THAM) as a buffering agent. This therapy rapidly improved her metabolic conditions. The patient was discharged 5 days after Intensive Care Unit admission in good condition and without neurological sequelae.