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- Volume 21, Issue 1, 2005
Southern African Journal of Critical Care - Volume 21, Issue 1, 2005
Volume 21, Issue 1, 2005
Source: Southern African Journal of Critical Care 21 (2005)More Less
The Critical Care Society committed in 2003 to improve the delivery of critical care in South Africa. One such commitment was to do an audit of the current critical care resources in South African public and private hospitals. Part 1 comprised a comprehensive audit which has now been completed. Part 2 is a 1-day prevalence study which is currently in the final planning stage, and part 3 will measure patient acuity levels in critical care.
Author Shelley SchmollgruberSource: Southern African Journal of Critical Care 21 (2005)More Less
The Critical Care Society of Southern Africa has recently become an associate member of the World Federation of Critical Care Nursing (WFCCN), and we now have a representative on that body's Council. The motivation was put forward by critical care nurses following a presentation by Professor Ged Williams, President of the WFCCN, at the annual Society conference in Durban. South Africa has a proud history of critical care nursing. The CCSSA has inspired critical care nursing leadership and development, by offering them a home within one of the largest medical organisations.
Author Ged WilliamsSource: Southern African Journal of Critical Care 21 (2005)More Less
It is my honour to greet the South African critical care community. I visited your wonderful country, albeit briefly, in 2004 and continue to marvel at the way in which you tackle many exciting challenges: clinically, professionally and socially. I do look forward to meeting many of you again in the future, but for now our correspondence is formal and written - I do hope that next time we speak it is overlooking a beach with a drink in our hand!
Author L. Rudo MathivhaSource: Southern African Journal of Critical Care 21 (2005)More Less
This issue of the Southern African Journal of Critical Care, which coincides with the 2005 COPICON congress, carries review articles on ventilatory therapy of critically ill patients. Giles offers a comprehensive review and practical guidelines on the provision of non-invasive ventilatory support, while Hamel and Cheifetz focus on the non-conventional mode of high-frequency oscillation, providing in-depth background information on the development and physiology of this mode of therapy, and outlining practical clinical guidelines for its initiation.
Author W.L. MichellSource: Southern African Journal of Critical Care 21 (2005)More Less
In this issue a paper by Joynt and Gomersall discusses the ethical issues in deciding which patients should receive life support in the form of mechanical ventilation. This is a particularly relevant topic in South African state hospitals, where intensive care beds are extremely limited yet the demand is potentially greater than in First-World countries because of our high incidence of severe trauma and infectious disease. Hospital administrators call for written admission policies, but developing these is a daunting task as few finite clinical criteria reliably predict death.
Author B. Louise GilesSource: Southern African Journal of Critical Care 21, pp 10 –15 (2005)More Less
Non-invasive ventilation (NIV) is a modality of providing airway and pulmonary support in both acute and chronic diseases of the lung. The method of mechanical ventilation without the use of an endotracheal tube was developed over a century ago, but its utility has only been explored recently with advances in technology. NIV is the method of choice when there is a desire to avoid the inherent complications that arise from using artificial airway supports such as endotracheal tubes and tracheostomies. NIV can be used in the intensive care unit and in the outpatient setting in appropriately selected patients. Adult and paediatric critical care and respiratory divisions have a wealth of experience in successful use of NIV. The history, use and experience will be discussed along with recommendations for initiating NIV.
Source: Southern African Journal of Critical Care 21, pp 15 –24 (2005)More Less
Since its inception over a decade ago, HFOV has become an increasingly utilised and effective strategy for the treatment of acute lung injury and acute respiratory distress syndrome. During HFOV, the lungs are recruited and stabilised to avoid the cyclic stretch and shear exerted on the alveoli which occur during conventional ventilation by repeated alveolar collapse and re-expansion. Patients with deteriorating gas exchange despite increasing ventilatory settings can be successfully managed with HFOV as it provides significant lung protection. However, as with any mode of ventilation, management strategies must be designed to minimise (or eliminate) ventilator-induced lung injury based on a patient's pathophysiology.
Author Tony WilliamsSource: Southern African Journal of Critical Care 21, pp 26 –31 (2005)More Less
Humidification of inspired gases is an essential part of modern intensive care practice, but there is wide international variation in the application of humidification devices. This review aims to briefly cover the reasons why humidification is important and the main methods of humidification used, outlining their different strengths and weaknesses.
Making moral decisions when resources are limited - an approach to triage in ICU patients with respiratory failureSource: Southern African Journal of Critical Care 21, pp 34 –44 (2005)More Less
In a number of countries around the world there is evidence that the demand for intensive care unit (ICU) resources exceeds supply. Epidemiological evidence suggests that future demands on intensive care resources will increase, adding to the burden of provision. Southern Africa almost certainly faces similar challenges, although there is as yet little published medical literature documenting this. When ICU resources are critically constrained, there is an inevitable need to ration the use of ICU beds. This means that while some patients who will potentially benefit from ICU care will be able to receive it, others will not. Assuming an absolute deficiency of ICU resources (available beds and their accompanying manpower requirement, equipment and other resources), the inevitable consequence is that some deserving patients will be denied potentially life-saving ICU care. A critically important decision must therefore be made - which patients will be admitted and which patients will be refused ICU care, and on what basis. A structured process of decision making is vital to maximise consistency and the moral defensibility of these difficult decisions. This paper will describe possible approaches to making these decisions, discuss aspects of triage in patients with respiratory failure, and examine some of the consequences of ICU triage.
Source: Southern African Journal of Critical Care 21, pp 46 –54 (2005)More Less
Background. In order to evaluate both outcome of intensive care unit (ICU) patients and ICU care, the risk-adjusted mortality can be calculated using the APACHE II equation. Our aim was to: (i) describe the case mix of admissions to our ICU; (ii) investigate the impact of such variation on outcome; and (iii) validate the use of the APACHE II risk prediction model in a developing country.
Methods. Prospective data collection of consecutive adult admissions over 13 months in a tertiary, predominantly medical, ICU. Survivors and non-survivors were compared for age, sex and diagnoses. ICU mortality was calculated for diagnostic categories and for the whole group. Risk of death was calculated according to the APACHE II method. The goodness of fit of the APACHE II equation was assessed with a calibration curve. The discrimination of the model was assessed with a receiver operator characteristic (ROC) curve.
Results. There were 304 admissions with an average APACHE II score of 17.4 and 37% ICU mortality. Diagnostic groups with high ICU mortalities included medical patients (42%), severe sepsis (59.4%), community-acquired pneumonia (CAP) (53%), pulmonary tuberculosis (45%) and immuno-compromised patients (62%). A calibration curve for the APACHE II equation, applied to our data, shows that the predicted ICU mortality was within the 95% confidence interval (CI) of the actual mortality. The only exception was the group with a 70% predicted risk of ICU death. The area under the ROC curve was 0.83 (95% CI: 0.78 - 0.88). The standardised mortality ratio was 0.98 (95% CI: 0.79 - 1.17).
Conclusions. This study validates the use of the APACHE II model to accurately describe the risk of ICU death of the patient population in a tertiary ICU in a developing country. Patients with severe sepsis and/or CAP had a significantly higher mortality. The main reason for this appeared to be a high risk of death at ICU admission. The principles of appropriate management of early sepsis should be taught to all doctors through continuing medical education.
Source: Southern African Journal of Critical Care 21, pp 57 –64 (2005)More Less