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- Southern African Journal of Critical Care
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- Volume 28, Issue 1, 2012
Southern African Journal of Critical Care - Volume 28, Issue 1, 2012
Volume 28, Issue 1, 2012
Author David M. LintonSource: Southern African Journal of Critical Care 28, pp 2 –3 (2012) http://dx.doi.org/10.7196/SAJCC.138More Less
I define an 'intelligent ventilator' as a dynamic and responsive machine that provides every patient with safe, efficient, synchronised, comfortable and appropriate ventilatory support through a continuous interactive process utilising four basic elements: on-line non-invasive respiratory function monitoring; initialisation of the most ideal ventilatory pattern for the current lung condition; automated closed-loop controlled adjustment of the ventilatory support in response to any change in the lung condition; and timely weaning from the ventilatory support in a safe and controlled fashion, without inducing any clinical deterioration of lung function.
Source: Southern African Journal of Critical Care 28, pp 6 –12 (2012) http://dx.doi.org/10.7196/SAJCC.130More Less
Objectives. Automated, microprocessor-controlled, closed-loop mechanical ventilation has been used in our Medical Intensive Care Unit (MICU) at the Hadassah Hebrew-University Medical Center for the past 15 years; for 10 years it has been the primary (preferred) ventilator modality.
Design and setting. We describe our clinical experience with adaptive support ventilation (ASV) over a 6-year period, during which time ASV-enabled ventilators became more readily available and were used as the primary (preferred) ventilators for all patients admitted to the MICU.
Results. During the study period, 1 220 patients were ventilated in the MICU. Most patients (84%) were ventilated with ASV on admission. The median duration of ventilation with ASV was 6 days. The weaning success rate was 81%, and tracheostomy was required in 13%. Sixty-eight patients (6%) with severe hypoxia and high inspiratory pressures were placed on pressure-controlled ventilation, in most cases to satisfy a technical requirement for precise and conservative administration of inhaled nitric oxide. The overall pneumothorax rate was less than 3%, and less than 1% of patients who were ventilated using only ASV developed pneumothorax.
Conclusions. ASV is a safe and acceptable mode of ventilation for complicated medical patients, with a lower than usual ventilation complication rate.
Source: Southern African Journal of Critical Care 28, pp 13 –16 (2012) http://dx.doi.org/10.7196/SAJCC.129More Less
Background. The monitoring of endotracheal tube (ETT) cuff pressure in intubated patients is important in preventing complications related to cuff over- and under-inflation.
Objectives. To explore and describe the existing practice related to ETT cuff pressure management by professional nurses in adult critical care units (CCUs) in the public and private healthcare sectors.
Method. A quantitative survey was used. Data were collected from professional nurses from adult CCUs in the public and private healthcare sectors in the Nelson Mandela Metropole, Eastern Cape, South Africa, using a structured self-administered questionnaire based on a literature review.
Results. The survey response was 75% (100/134). Practice variances included the frequency of cuff pressure monitoring: only 52% of respondents performed cuff pressure measurements every 6 - 12 hours; 32% reported performing measurements at 2 - 4-hourly intervals; 15% only assessed cuff pressure when a leak occurred; and 1% never monitored cuff pressure. Of the 100 respondents, 37% used the cuff pressure measurement (CPM) method, 24% used the palpation method or listened to air leaks, and 22% used minimal occlusive volume (MOV). None of the respondents used the minimal leak technique (MLT). Only 20% of the respondents maintained cuff pressures at 18 - 22 mmHg. Thirty-one per cent indicated that they still performed the practice of cuff deflation and re-inflation before and after suctioning. There were incongruities related to the management of air leaks and the amount of air instilled.
Conclusion. Practice variances were noted among the professional nurses, especially in the private healthcare sector. The lack of evidence-based clinical decision-making related to cuff pressure management in mechanically ventilated patients was evident. Best practice recommendations need to be used effectively when performing ETT cuff pressure management, to reduce practice variance, standardise safe patient care, and minimise complications.
Intra-abdominal pressure at ICU admission : evaluation as a predictor of severity and mortality in severe acute pancreatitisSource: Southern African Journal of Critical Care 28, pp 17 –21 (2012) http://dx.doi.org/10.7196/SAJCC.134More Less
Background and aims. Approximately 20% of acute pancreatitis progresses to a severe form characterised by multiple extrapancreatic organ dysfunction. Elevated intra-abdominal pressure (IAP), a frequent finding in these patients, further adds to the mortality. Currently used prognostication indices have their own set of limitations. We evaluated IAP at intensive care unit (ICU) admission as a predictor of mortality in severe acute pancreatitis (SAP).
Methods. A retrospective analysis of 50 patients with SAP admitted to the ICU of a tertiary-care Indian institute over a period of 3 years was done. Data relating to demographic profile, cause of pancreatitis, ICU admission, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, IAP, interventions instituted and mortality were analysed.
Results. Biliary stones (38%) were the most common cause of acute pancreatitis. Survivors differed from non-survivors with respect to organ failure, APACHE II and SOFA scores and IAP on admission. There was a significant correlation between IAP on ICU admission and admission SOFA (r=0.56, p<0.001) and APACHE II (r=0.54, p<0.001) in predicting mortality. Patients with elective admission had a mortality rate of 53% (20/38) compared to 83% (10/12) for those admitted as emergencies. Analysis of receiver operating characteristic curves for detecting mortality revealed an area under the curve of 0.915 (95% confidence interval (CI) 0.83 - 0.99) for IAP, 0.826 (95% CI 0.71 - 0.93) for SOFA, and 0.831 (95% CI 0.71 - 0.94) for APACHE II.
Conclusion. IAP at ICU admission is a useful predictor of severity of illness and mortality in SAP.
Source: Southern African Journal of Critical Care 28, pp 22 –27 (2012) http://dx.doi.org/10.7196/SAJCC.122More Less
Introduction. There has been a notable increase in the incidence of elderly patients being admitted to intensive care units (ICUs), globally and in Morocco. Studies on the diagnosis and management of ICU patients often exclude subjects with multiple co-morbidities or those older than 80 years. However, as the world's population becomes increasingly old and ill, this subset will require ICU admission more frequently and their management will pose a serious challenge to the intensivists treating them. There are no studies in the current medical literature from low- or middle-income countries assessing the outcome of elderly patients admitted to ICUs. Specifically, little is known about the outcome of elderly patients admitted to ICUs in Morocco.
Aims. The aims of the present study were to analyse the characteristics of elderly Moroccan patients (aged ≥65 years) admitted to a medical ICU, and to identify factors predicting ICU mortality.
Methods. This was a retrospective study conducted in the medical ICU of a Moroccan university hospital. All elderly patients (≥65 years) with complete records were included, whatever their length of stay. Baseline characteristics, clinical parameters and severity of illness were recorded at admission. Patients were grouped according to their survival status using logistic regression analysis.
Results. During the study period, 1 072 patients were admitted to the ICU, of whom 16.6% (n=179) were aged >65 years and had complete records. Fifty-five per cent (n=98) were men. The median age was 70 years (interquartile range 67 - 75 years). The overall ICU mortality was 44.7%, and 64% of deaths occurred within 5 days of admission. On univariate analysis, the factors predicting mortality were alcohol misuse (p=0.09), pneumonia (p≤0.001), shock (p=0.001), dehydration (p=0.007), urine output ≤0.5 ml/kg/h (p =0.003), serum urea level >16.6 mmol/l (p=0.01), serum creatinine level >159 µmol/l (p=0.005), and an abnormality on the chest radiograph (p=0.01). The Sequential Organ Failure Assessment (SOFA) score was the most accurate predictor of ICU mortality in this group of elderly patients, with an area under the curve (AUC) of 0.775 (standard deviation (SD) ±0.036). The Acute Physiology and Chronic Health Evaluation II (APACHE II) score also performed adequately (AUC 0.757; SD ±0.037), but the Simplified Acute Physiology Score II (SAPS II) and Logistic Organ Dysfunction System (LODS) scores were not useful in this group. Two parameters significantly associated with mortality risk were shock (odds ratio (OR) 11.5, 95% confidence interval (CI) 3.7 - 35.7; p<0.001) and pneumonia (OR 3.13, 95% CI 1.5 - 6.2; p<0.001).
Conclusion. Admission of aged patients to the ICU raises important medical, ethical, sociological and economic questions. Our findings suggest that severity of illness, shock and pneumonia on ICU admission were the independent risk factors associated with raised mortality, 64% of which occurred within 5 days of ICU admission.