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.     

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.     

Outcome after admission to an intensive care unit. A 6-week study at Baragwanath Hospital

This study reports the short- medium- and long-term outcome of treatment in patients admitted to the Baragwanath Hospital Intensive Care Unit; 81% were discharged in a satisfactory state, but the morbidity rate of 11% was unacceptably high.     

Predicting mortality for critically ill burns patients,using the Abbreviated Burn Severity Index and Simplified Acute Physiology Score 3

Introduction: Reviewing the profile of patients admitted at the Burns Intensive Care Unit at São Paulo Hospital – UNIFESP, as well as the available literature, it becomes evident the need for tools able to predict those patients’ outcomes. Distinct score models are used in different health centers, not only as prognostic models, but also as research and quality control tools. Amongst these prognostic scores, there are two strands, the burns specific scores – which consider the injury's characteristics – and the general critical patient's scores. Objective: This study aims to analyze the differences and tendencies in mortality prediction of two broadly used scores when applied to São Paulo Hospital's Burns Intensive Care Unit patients, ABSI – burns specific score – and SAPS 3 – general score for critical patients. Methods: This is an individual, observational, retrospective and comparative study, developed with medical records review. Both scores were applied to every patient admitted at São Paulo Hospital's Burns Intensive Care Unit from 2011 to 2016. Statistical analyses used the non-parametric test of Kolmogorov-Smirnov, a p-value <0.05 was considered significant. Results: 122 patients were included, the average age was 34,4 years old. 70,5% of patients were male and 49% had a total body surface area burned of 20%. 27% of the patients died. Statistical analyses do not show significant differences between ABSI and SAPS3 mortality predictions for burns patients at this health center. Conclusion: The study evidences that SAPS 3 score, frequently used at general Intensive Care Units, has a similar performance to ABSI score, which is specific for burns populations. ABSI score is easier to implement, as it is simpler and able to show instant results.     

Colloid solutions in the critically ill

All patients admitted to an Intensive Care Unit were assigned randomly to one of two groups, A and B. Group A received colloid volume replacement as 4.5% albumin whilst group B received a synthetic colloid, polygeline. This study describes the changes in serum albumin concentration in survivors and nonsurvivors in the two groups during their stay in the Intensive Care Unit. The incidences of renal failure and pulmonary oedema were also assessed. Serum albumin concentration decreased in all nonsurvivors. In survivors the serum albumin concentration decreased to a greater extent in the synthetic colloid group than in the albumin group. Despite the differences in serum albumin concentration there were no significant differences between the groups in the incidences of pulmonary oedema or renal failure.     

Criteria for elective admission to the paediatric intensive care unit following adenotonsillectomy for severe obstructive sleep apnoea

During the period 1997 to 2002, 42 children were electively admitted to the Paediatric Intensive Care Unit at the John Hunter Children's Hospital following adenotonsillectomy for severe obstructive sleep apnoea. Forty children had a preoperative sleep study, of which 33 were complete polysomnograms. Of the 42 children admitted, 35 required no intervention while seven (17%) required an additional intervention beyond supplemental oxygen. Our criteria for elective admission to Paediatric Intensive Care following adenotonsillectomy for severe obstructive sleep apnoea are presented.     

CLONIDINE IN THE TREATMENT OF ALCOHOL WITHDRAWAL IN THE INTENSIVE CARE UNIT

We present two cases of patients with a past history of alcoholabuse admitted to the Intensive Care Unit (ICU) for treatmentof respiratory problems, after multiple trauma and after sub-totalcolectomy, respectively. In both patients, features of alcoholwithdrawal were prominent after sedation had been discontinued.Both were treated successfully with an infusion of clonidine.     

Vascular surgery patients in intensive care: a bi-national cohort study over 15 years

Background

To describe the characteristics and outcomes of patients admitted to Intensive Care following vascular surgery, and their subsequent usage of Intensive Care resources, over a 15-year period in Australia and New Zealand.

Methods

This was a retrospective, bi-national study of 69 676 adult patients admitted to 179 Intensive Care Unit (ICUs) following vascular surgery between January 2005 and December 2019, using the Australian and New Zealand Intensive Care Society Adult Patient Database.

Results

The proportion of ICU bed days used by vascular surgery patients decreased during the study period from 3.6% in 2005 to 2.9% in 2019 (P < 0.001). The cohort had a median age of 73 years, and were most frequently admitted after a carotid endarterectomy (22%) or elective open aneurysm repair (20%). A total of 5.2% of patients did not survive to discharge. Mean annual adjusted mortality decreased during the study period from 6.1% in 2005 to 3.7% in 2019 (P < 0.001). Multiple factors were associated with higher mortality, including gender, hospital case volume and hospital type.

Conclusions

Between 2005 and 2019 survival for vascular surgery patients requiring ICU admission in Australia and New Zealand improved. During the same time the proportion of ICU bed days used by these patients decreased.     

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.     

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.     

A survey of infection in an intensive care unit ''Forewarned is forearmed''

The infection (36%) and mortality rates (28%) were investigated in 433 patients admitted to a Respiratory Intensive Care Unit. It was found that the mortality rate was higher (45%) in the infected group than in the non-infected group (19%) and particularly so in patients who had had intra-abdominal surgery or who remained in the unit for longer than a week.     

Analysis of the head injuries admitted to the Oxford Regional Neurosurgical Unit 1980-1982

We have reviewed the patients with head injuries referred to the Oxford Regional Neurosurgical Unit over a 2-year period (1980-1982). In 73 per cent of the cases the referring surgeon suspected an intracranial collection or was experiencing difficulty in managing the patient. Eighty-one per cent of these patients required nursing in the Intensive Care Unit; 32 per cent underwent operative intervention. The total numbers admitted were low and this may suggest that many patients with severe head injuries are being treated in the district general hospitals when ideally they should be transferred to a neurosurgical unit. Adherence to suggested guidelines for transference would necessitate increased neurosurgical facilities.     

The role of anaesthetists in the Darwin response to the Bali bombing

The bombing of nightclubs in Bali on the night of October 12, 2002 was one of the worst peacetime disasters affecting Australians. This paper examines the unique role of anaesthetists in helping manage the victims, with the main emphasis on events in Darwin. Anaesthetists were involved in the multiple stages of patient care; from the hospital in Bali, evacuation to Darwin, resuscitation and onward evacuation to burns units around Australia as well as definitive surgical management. We discuss the role of anaesthetists in disaster management.     

Candida. A decreasing problem for the burned patient?

Multiple recent reports have suggested that Candida wound infection and sepsis are major complications of severe burn injury. Our current burn treatment plans include aggressive early burn excision and grafting, avoidance of invasive monitoring and central hyperalimentation lines, enteral nystatin, and judicious use of antibiotics. A retrospective review of 168 severely burned patients admitted to the Intensive Care Unit of the University of Washington Burn Center, Seattle, during the 18-month period from June 1984 through December 1985 was undertaken. Thirteen percent of these patients had one or more cultures positive for Candida from any site. Three patients (1.8%) developed Candida sepsis, which was diagnosed on the basis of clinical signs of sepsis, a positive blood culture for Candida, and at least two additional culture sites positive for Candida. All three patients were treated with amphotericin B. One of these patients died of Candida sepsis, for an overall mortality of 0.6%. Therefore, Candida septicemia was not a major cause of morbidity or mortality in our burn patients in the Intensive Care Unit during this 18-month period under the current management regimen.     

Quality of life after intensive care in trauma patients

Published studies and our own preliminary results show that Intensive Care Unit (ICU) patients admitted after severe trauma, all report reduced quality of life (QOL) after discharge. In contrast to other ICU patients, this reduction is decreased by time, but does not seem to reach pre-ICU levels. Interventions to improve this situation have not been documented. This should be a high priority aspect for all health personnel caring for patients surviving severe trauma.     

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.     

Failed Emergency Department disposition to the ward of patients with thoracic injury

AIMS: To characterise patients who were admitted to the ward following Emergency Department (ED) management for thoracic injury yet went on to require Intensive Care Unit (ICU) admission. To identify risk factors for failed ward management. METHODS: All patients admitted to the ward following chest trauma from 2002 to 2006 were identified from the Alfred Hospital trauma database. Patients who went on to require ICU admission were compared to those admitted to and discharged from the ward without requiring ICU. Possible predictors of ICU admission were analysed. RESULTS: There were 764 patients during the study period who were admitted to the ward following chest trauma. Of these, 70 patients went on to require Intensive Care admission. Patients requiring ICU admission spent a significantly longer time in hospital and required significantly more rehabilitation. Multivariate analysis using stepwise logistic regression confirmed intercostal catheter (ICC) insertion and higher injury severity scores as significant independent variables associated with ICU admission. Associated abdominal injury, along with multiple rib fractures and flail were also predictive of failed ward management. CONCLUSION: This study demonstrated that intercostal catheter insertion (tube thoracostomy) was an independent risk factor for deterioration following admission along with multiple rib fractures and certain associated injuries. This should be considered when admitting patients to the ward.     

Pediatric bicycle trauma

Bicycle-related trauma is a serious pediatric problem. Serious injuries and even fatalities can occur, and care must be taken to avoid undertreating these patients. In an effort to further define the problem, 201 consecutive patients admitted for bicycle trauma were reviewed. The patients ranged in age from 3 to 16 years and 76% (153/201) were male. Head trauma was the most common admission diagnosis (99/201; 49%). Fourteen per cent (28/201) were admitted to the Intensive Care Unit and 23% (47/201) required an operative procedure. The average hospital stay was 3 days; however, patients who were admitted at least 24 hours after injury had an average hospital stay of 7 days.     

Steroids in croup: do they increase the incidence of successful extubation?

Between January 1983 and July 1988, 2623 patients with croup were admitted to the Royal Children's Hospital, Melbourne. A total of 416 patients (16%) were admitted to the Intensive Care Unit and 176 of these patients required intubation. Of these patients 117 patients were successfully extubated at the first attempt and 59 needed reintubation. Of the patients who were reintubated 35 were given steroids prior to subsequent extubation attempts. Only one patient who had received steroids failed extubation. Of those who did not receive steroids 59% required reintubation. In patients with croup who fail the first extubation the results of this study suggest that steroids significantly increase the success of subsequent extubations.     

The requirement for intensive care support for the pregnant population

Pregnancy-associated admissions to the Intensive Care Unit during the first 5 years of a newly established teaching hospital obstetric unit are reviewed. There were 23 such admissions; in the same period, 21,983 deliveries occurred. The most frequent cause for Intensive Care admission was hypertensive disease of pregnancy. Most patients required admission for less than 48 hours. Two patients died during the period of study.