Southern African Journal of Critical Care
SAJCC is the official journal of the Critical Care Society and is sent to the members of CCS, intensive care nurses, paramedics and medical practitioners.
|Publisher||Health and Medical Publishing Group (HMPG)|
|Coverage||Vol 20 Issue 1 Aug 2004 - current|
Abstracts of scientific presentations at the 2016 Annual National Conference of the Critical Care Society of Southern Africa : abstracts
Does prone positioning recruit dorsal lung regions in children with acute respiratory distress syndrome (ARDS)?
Prognosis of myocardial infarction and myocardial injury following vascular surgery
Postoperative outcome of intensive care unit (ICU) surgical patients at a Zimbabwean hospital
Yellow fever outbreak: Experience in an Angolan intensive care unit (ICU)
Paediatric cardiac critical care admissions to a tertiary paediatric intensive care unit (PICU)
ALCAPA in children: Single-centre perioperative outcome
The impact of echocardiography in a paediatric intensive care unit (PICU)
Children with fulminant dilated cardiomyopathy or myocarditis
Factors associated with survival to discharge of newborns in a tertiary hospital
The role of the intensive care unit (ICU) nurse in antimicrobial stewardship in a private hospital
Elevated lactate from three different mechanisms - a case series
Development of a paediatric simulation programme
Tracheostomy, one of the oldest known surgical procedures in the history of medicine, is regularly performed in modern intensive care units. Acquired ulcerative tracheo-oesophageal fistula (TOF) is an uncommon but potentially fatal complication of tracheostomy. We report a case of ulcerative TOF with an unusual yet characteristic presentation, in a ventilator-dependent tracheostomised patient with Guillain-Barré syndrome. It presented as sudden progressive severe abdominal distension that was rhythmic with each ventilator breath. The predisposing factors, clinical features and preventive measures of post-tracheostomy TOF are discussed in this case report. Regular monitoring of tracheal tube cuff pressures and volumes, along with avoidance and treatment of various predisposing factors, are advisable for the prevention of this serious consequence.
Incidence and risk factors for thrombocytopenia in the intensive care units of a tertiary hospital in northern India
Background. In Western countries, incidence of thrombocytopenia in intensive care units (ICUs) has been found to be 13 - 44%. We chose to study the incidence, risk factors and transfusion requirements of thrombocytopenia in tertiary care ICUs in northern India.
Objective. To study the incidence and risk factors of thrombocytopenia in a mixed ICU.
Methods. This prospective observational 6-month cohort study was conducted in two 22-bedded medical-surgical ICUs. Patients aged 18 years or older with an ICU stay of at least 2 days were included.
Results. Thrombocytopenia (<150 000/dL) occurred in 190 (38%) of the 500 patients studied. Thrombocytopenia was present on admission in 41 (8%) patients. Of the remaining patients, 149 (32%) developed new-onset thrombocytopenia (NOT) - thrombocytopenia developing in patients with platelet count more than 150 000/U on admission - during ICU stay. Incidence and prevalence were 30% and 38%, respectively. ICU mortality was 13%. Thrombocytopenia was commonly associated with sepsis, disseminated intravascular coagulation, heparin and certain antibiotics. Cause could not be established in 10 patients. Underlying coronary artery disease and sepsis correlated with thrombocytopenia. Mortality was higher in patients with NOT (15.4 v. 8.7%, p=0.003). Compared with non-thrombocytopenic patients, patients with NOT required more blood product transfusions (57.7 v. 38.4%, p=0.000) and mechanical ventilation (23.5 v. 13.5%, p=0.008). No difference was observed in length of hospital stay and bleeding risk between the two groups.
Conclusion. We found incidence and prevalence of thrombocytopenia in the ICU comparable with internationally reported figures. NOT was associated with higher mortality and morbidity and may be considered as a marker of disease severity.
An observational study on the relationship between plasma vitamin C, blood glucose, oxidative stress, endothelial dysfunction and outcome in patients with septic shock
Background. Septic shock is associated with endothelial dysfunction and oxidative stress, against which vitamin C plays a protective role, possibly influencing clinical outcome. Hyperglycaemia may lower vitamin C.
Objective. To study plasma vitamin C, oxidative stress, hyperglycaemia, endothelial dysfunction and outcome in septic shock.
Methods. In a prospective, observational study of 25 adult septic shock patients, serial blood samples were analysed for vitamin C, thiobarbituric acid-reactive substances (TBARS) (a biomarker of oxidative stress), and soluble vascular cell adhesion molecule-1 (sVCAM-1) and E-selectin (markers of endothelial dysfunction). Blood glucose, Sequential Organ Failure Assessment (SOFA) scores and fluid requirements were monitored.
Results. Plasma vitamin C was low, while plasma TBARS were high throughout the 7-day study period. Endothelial dysfunction markers (sVCAM-1 and E-selectin) were high at the baseline. VCAM-1 decreased significantly on day 1 and normalised on day 7. E-selectin was unchanged on day 1 compared with baseline, but increased significantly on day 7. Oxidative stress and endothelial dysfunction were associated with increased SOFA score. Increased oxidative stress was associated with increased requirements for intravenous fluids and prolonged duration of vasoconstrictor support. Nine patients died in hospital. At baseline, levels of TBARS were significantly higher in non-survivors than in the survivors of septic shock.
Conclusion. In septic shock, clinically relevant oxidative stress was associated with endothelial dysfunction, low vitamin C and high glucoseto-vitamin-C ratios. Markers of oxidative stress and endothelial damage were increased and correlated with resuscitation fluid requirements, vasoconstrictor use, organ failure and mortality.
There has been a decline in ventilator-associated pneumonia (VAP) in the paediatric intensive care units of developed countries. Previous studies at the Red Cross War Memorial Children's Hospital give an incidence of VAP of >40/1 000 ventilator days, identifying VAP as a priority area for practice improvement. We outline the process and outcome of a practice improvement initiative that implemented an evidence-based bundle of care to reduce VAP. In 2011, this initiative was taken to improve healthcare-associated infections, with the support of the 'Best Care Always' project. A task team identified an evidence-based bundle of care aimed at reducing VAP. The bundle consisted of five elements that were adjusted practically to suit the unit. Standardised metrics to measure compliance with the bundle and outcomes of the intervention were instituted and collected prospectively throughout the study period. Following implementation in October 2011, VAP rates decreased from 55/1 000 to 19.1/1 000 ventilator days over the first 5-month period. During this period, compliance remained poor and metrics were poorly collected. With the introduction of a full-time VAP coordinator, compliance improved from 57% to a peak of 83%, with a decrease in VAP to an average of 4/1 000 ventilator days (January 2013 - July 2013). This practice improvement initiative resulted in a significant reduction in VAP. The success of this initiative is attributed equally to the introduction of the bundle of care and driving power of the VAP coordinator.
Background. Physiotherapists are integral members of the interprofessional team that provides care and rehabilitation for patients in intensive care units (ICUs).
Objectives. To describe the current practice of physiotherapists in ICUs, determine if physiotherapists' practice has changed since a previous report and determine if practice is evidence based.
Methodology. A questionnaire was content validated and made available electronically and in hard copy. Physiotherapists who work in ICUs in public or private sector hospitals or who are members of the South African Society of Physiotherapy were identified and invited to participate.
Results. Survey response rate was 33.9%. Patient assessment techniques performed 'very often' included ICU chart assessment (n=90, 83.3%), chest auscultation (n=94, 81.8%) and cough effort (n=81, 75%). Treatment techniques performed 'very often' included manual chest clearance (n=101, 93.5%), in-bed mobilisation and positioning (n=91, 84.3%; n=91, 84.3%, respectively), airway suctioning (n=89, 82.4%), out-of-bed mobilisation (n=84, 77.8%), deep breathing exercises (n=83, 76.9%) and peripheral muscle-strengthening exercises (n=72, 73.1%). More respondents used intermittent positive pressure breathing (57 v. 28%, p=0.00), used adjustment of mechanical ventilation (MV) settings (30 v. 15%, p=0.01), were involved with weaning patients from MV (42 v. 19%, p=0.00) and used incentive spirometry (76 v. 46%, p=0.00) than reported previously. More respondents performed suctioning (99 v. 70%, p=0.00), extubation (60 v. 25%, p=0.00) and adjustment of MV settings (30 v. 12%, p=0.02) than reported internationally.
Conclusion. Physiotherapy practice in ICUs is evidence based. Care focuses largely on mobilisation, exercise therapy and multimodality respiratory therapy.