Vascular surgery, ICU and HDU: a 14-year observational study

INTRODUCTION

Over the course of the past decade, numerous changes have occurred in the management of patients undergoing vascular surgical operations. The introduction of high dependency units (HDUs) has meant that many patients previously requiring observation in intensive care units (ICUs) are now managed in this new environment. In addition, many vascular patients may now be suitable for management on a vascular ward immediately following their surgery. This study reports the chronological changes in resource utilisation of patients undergoing major vascular surgery in a district general hospital over a 14-year period.

PATIENTS AND METHODS

Details of all patients admitted to either the ICU or HDU under the care of a single vascular surgeon during the period 1991–2004 were extracted from a prospectively maintained anaesthetic department database. Details of the age and gender of the patients were obtained together with source of admission, place of discharge and need for re-admission. Operative details for each patient were extracted from a prospectively maintained vascular surgery database including type of procedure undertaken and degree of urgency.

RESULTS

During the 14-year period under study, there was a dramatic decrease in the use of ICU facilities for the management of vascular patients from 100% in 1991 to 36% in 2004. There was a corresponding increase in the use of HDU for major vascular cases during the same period from 0% to 66%. However, despite a significant increase in the total number of major vascular operations performed, from 67 in 1991 to 185 in 2004 as a result of sub-specialisation, overall use of all high-care facilities fell as the number of patients returned directly to the vascular ward increased from 34% in 1991 to 64% in 2004. The efficacy of the choice of management venue was confirmed by the observation that only 7.7% of those managed on ICU had been initially managed at a lower level of care. In addition, only 1.8% of patients managed on HDU had been admitted after initially being managed on the vascular ward.

CONCLUSIONS

Sub-specialisation over the past decade has meant a significantly increased major vascular work-load. Since the introduction of the HDU, there has been a significant fall in the use of ICU facilities for routine cases. These changes in resource utilisation have significant implications in terms of budget allocation. It would appear that finances, in relation to vascular surgery, should be concentrated on expanding HDU facilities and ensuring vascular surgery expertise amongst ward nursing staff.     

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS): experience with high-dose intravenous immunoglobulins and topical conservative approach. A retrospective analysis

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are rare, drug-induced, severe acute exfoliative skin and mucosal disorders. Several treatments previously proposed have produced contradictory results in small series; in 1998 the use of intravenous immunoglobulins (IVIG) was introduced with excellent clinical findings. Our experience (1999-2005) using IVIG in the therapy of TEN/SJS, together with a local conservative approach, is reported and related to our previous treatments (1993-1998). The SCORTEN and the standardized mortality ratio (SMR) was used to evaluate the efficacy of our therapeutic modalities. Eight patients were treated before IVIG era and 23 patients have been treated with IVIG. There was no significant difference in SCORTEN between the two groups. Concerning the local approach, a conservative wound management in IVIG series replaced an extensive epidermal debridment and coverage with artificial skin substitutes of the pre-IVIG series. Overall mortality in patients treated before IVIG was 75% (6/8), in the IVIG group it decreased to 26% (6/23) with a cessation of further epidermal detachment after an average of 5 days (3-10 days) from the onset of the therapy. The SMR showed a trend to lower actual mortality (not significative) with IVIG treatment than the predicted mortality (SMR=0.728; 95% CI: 0.327-1.620).     

Design and preliminary results of FRENSHOCK 2016: A prospective nationwide multicentre registry on cardiogenic shock

Central illustration: geographic distribution of the 49 centres participating in the FRENSHOCK registry (35 academic hospitals, 10 general hospitals and four private clinics). Inclusion per centre varied from 1 to 72 patients.

     

专科医院ICU重症监护信息系统护理文书的优化与效果评价

目前国内外医院信息系统建设重点已由医院管理信息系统（hospitalinformationmanagementsystern,HMIS）转向临床信息系统（clinicinformationsystem,CIS）。据统计,美国25％的1000张床位以上大型医院使用了CIS。国内的CIS处于理论探索和临床初步摸索阶段,与国际先进水平相比还有较大的差距。     

Prevalence of pressure injuries and the management of support surfaces (mattresses) in adult intensive care patients: A multicentre point prevalence study in Australia and New Zealand

BackgroundPressure injuries (PIs) are a patient safety issue that impact patient outcomes. Intensive care unit (ICU) patients are at high risk of PIs.ObjectivesTo report the prevalence and classification of documented PIs in adult ICU patients, the use of pressure injury risk assessment tools, and support surface management as a part of the prevention of PIs.MethodsThis was a prospective, single-day, multicentre, cross-sectional study of patients aged ≥ 16 years admitted to adult ICUs in Australia and New Zealand (ANZ), August 2016 as part of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS-CTG) Point Prevalence Program.FindingsData were collected on 671 patients (58% male) in 47 ICUs. The mean [standard deviation] age and weight were 60.2 years [17.2 years] and 82.1 kg [29.7 kg], respectively, with a severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II) of 18.2 [8.4]. PIs were reported in 10% (70/671) of patients. Patients with a PI had a mean APACHE II score of 22.5 [standard deviation; 7.7], and 57.1% (40/70) met the criteria for sepsis on the study day. There were 107 PIs documented on the study day (N = 107) in the 70 patients with nearly half of PIs present on ICU admission (46.7%; 50/107). The sacrum was the most common location for PIs (28.9%; 31/107) and then the heels (15.9%; 17/107). All units routinely use a risk of PI assessment tool and were cared for on an active or reactive support surface. Patients with a PI were more often moved to an active support surface.ConclusionsThe prevalence rate was reported at 10% for PIs for adult intensive care patients on the study day. More than half of the patients with a PI had signs of sepsis on the study day and a higher severity of illness, and more were cared for on active support surfaces. Most PIs were located at the sacrum and then the heels. All clinical sites routinely used a PI risk assessment tool.     

Room for improvement in breast milk feeding after very preterm birth in Europe: Results from the EPICE cohort

Breast milk feeding (BMF) is associated with lower neonatal morbidity in the very preterm infant (<32 weeks gestation) and breastfeeding is beneficial for maternal health. Previous studies show large variations in BMF after very preterm birth and recognize the need for targeted breastfeeding support in the neonatal intensive care units (NICU). In a European collaboration project about evidence‐based practices after very preterm birth, we examined the association between maternal, obstetric, and infant clinical factors; neonatal and maternal care unit policies; and BMF at discharge from the NICU. In multivariable analyses, covariates associated with feeding at discharge were first investigated as predictors of any BMF and in further analysis as predictors of exclusive or partial BMF. Overall, 58% (3,826/6,592) of the infants received any BMF at discharge, but there were large variations between regions (range 36–80%). Primiparity, administration of antenatal corticosteroids, first enteral feed <24 hr after birth, and mother's own milk at first enteral feed were predictors positively associated with any BMF at discharge. Vaginal delivery, singleton birth, and receiving mother's own milk at first enteral feed were associated with exclusive BMF at discharge. Units with a Baby Friendly Hospital accreditation improved any BMF at discharge; units with protocols for BMF and units using donor milk had higher rates of exclusive BMF at discharge. This study suggests that there is a high potential for improving BMF through policies and support in the NICU.     

脑缺血/再灌注损伤对小鼠海马区胶质细胞的影响

目的探讨小鼠脑缺血/再灌注后胶质细胞形态学与数量的变化及其临床意义。方法采用随机方法将32只健康昆明雄性小鼠分为假手术组和模型组,每组16只。制备脑缺血/再灌注损伤模型,应用免疫组织化学方法分别标记星形胶质细胞特异性蛋白胶质纤维酸性蛋白(glial fibrillary acidic protein,GFAP)与小胶质细胞特异性蛋白离子钙接头蛋白抗体(ionized calcium-binding adaptor molecule 1,Iba-1),观察脑缺血/再灌注小鼠海马区胶质细胞形态及数量的变化。结果脑缺血/再灌注损伤后模型组小鼠海马区锥体细胞排列紊乱,细胞脱失明显,细胞核体积变小,深染,呈核固缩。GFAP与Iba-1阳性细胞在形态上表现为胞体肥大,分支变粗;模型组阳性细胞数分别为(12.56±1.58)个/HP和(9.63±1.50)个/HP,均显著多于假手术组,差异具有统计学意义(P<0.01)。结论小鼠局灶性脑缺血/再灌注损伤后海马区胶质细胞过度活化,可能参与加重脑缺血/再灌注后组织损伤及神经元凋亡。