Southern African Journal of Critical Care - Volume 30, Issue 1, August 2014

All intubated adults and children managed in an intensive care unit (ICU) require endotracheal suctioning in order to maintain a patent airway. Patients cannot eliminate secretions themselves, partly because the presence of the endotracheal tube (ETT) compromises glottic closure, thereby limiting the pressures and velocity of airflow that can be generated for an effective cough. In addition, normal mucociliary function may be impaired by inadequately humidified inspired gas. The ETT itself may cause irritation of the airways and increased secretion production, and in the presence of respiratory infection the increased amount and viscosity of pulmonary secretions further impede clearance.

Patients are admitted to an intensive care unit (ICU) because their illness or injury may be life-threatening, requiring intense support and monitoring that cannot be given in the general wards. Critical illness is often sudden, unexpected and can change the lives of both the patient and family members in a matter of minutes. The everyday lives of family and close friends may come to an abrupt halt or be disrupted as they live in the uncertainty of not knowing whether the patient will survive. The ICU, a stressful, unfamiliar, alien and intimidating environment, often becomes the centre of people's lives as they wait desperately for any signs of alterations or progress in the lives of their loved ones. The lives of the patients admitted to ICU are often in danger, which can lead to anxiety, depression and post-traumatic stress disorder in their family members.

Background. The admission of a relative to an intensive care unit (ICU) is a stressful experience for family members. There has been limited research addressing this issue in Kigali, Rwanda.

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Objective. To explore the needs of patient family members admitted into an ICU in Kigali, Rwanda.

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Methods. This study used a quantitative exploratory design focused on exploring the needs of patient family members in ICU at one hospital in Kigali, Rwanda. Family members (N=40) were recruited using the convenience sampling strategy. The Critical Care Family Needs Inventory was used to collect relevant data.

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Results. The participants identified various needs to be met for the family during the patient's admission in ICU. The most important was the need for assurance, followed by the need for comfort, information, proximity and lastly support. Three additional needs specific to this sample group were also identified, related to resource constraints present in the hospital where the study was carried out.

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Conclusion. These results offer insight for nurses and other healthcare professionals as to what the important needs are that must be considered for the patient family members in ICUs within a resource-constrained environment.

Background. Paediatric Index of Mortality (PIM) and PIM 2 scores have been shown to be valid predictors of outcome among paediatric intensive care unit populations in the UK, New Zealand, Australia and Europe, but have never been evaluated in the South African context.

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Objective. To evaluate the PIM and PIM 2 as mortality risk assessment models.

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Method. A retrospective audit of case records and prospectively collected patient data from all admissions to the Paediatric Intensive Care Unit (PICU) of Red Cross War Memorial Children's Hospital, Cape Town, during the years 2000 (PIM) and 2006 (PIM 2), excluding premature infants, children who died within 2 hours of admission, or children transferred to other PICUs.

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Results. For PIM and PIM 2 there were 128/962 (13.3%) and 123/1113 (11.05%) PICU deaths with expected mean mortality rates of 12.14% and 12.39%, yielding standardised mortality risk ratios (SMRs) of 1.1 (95% confidence interval (CI) 0.93 - 1.34) and 0.9 (95% CI 0.74 - 1.06), respectively. Receiver operating characteristic analysis revealed area under the curve of 0.849 (PIM) and 0.841 (PIM 2). Hosmer-Lemeshow goodness of fit revealed poor calibration for PIM (X²=19.74; p=0.02) and acceptable calibration for PIM 2 (X²=10.06; p=0.35). SMR for age and diagnostic subgroups for both scores fell within wide confidence intervals.

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Conclusion. Both scores showed good overall discrimination. PIM showed poor calibration. For PIM 2 both discrimination and calibration were comparable to the score derivation units, at the time of data collection for each. Calibration in terms of age and diagnostic categories was not validated by this study.

Objective. To assess the knowledge of nurses working in intensive care units (ICUs) in respect of pain management, glycaemic control and weaning from mechanical ventilation.

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Methods. An analytical, cross-sectional survey design was used. All ICU-trained and non-ICU-trained registered nurses (N=136) working in the ICUs of selected public and private hospitals were invited to participate.

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Results. The knowledge of both the ICU-trained and non-ICU-trained nurses was found to be lacking. The overall mean score (standard deviation) obtained was 47.56% (11.61). The ICU-trained participants obtained 50.11% (11.96) and non-ICU-trained participants obtained 45.01% (10.75). This difference, although small, was statistically significant (p=0.0099). A poor relationship was found between level of knowledge and years of ICU experience.

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Conclusion. Nurses lack knowledge in the three care areas tested. ICU nurses' experience cannot be relied upon as a source of knowledge for decision-making about protocol-directed care. It is suggested that on-going educational programmes be introduced into ICUs to address this shortfall in knowledge.

Background. The process of actively attempting to revive a patient in cardiac arrest while in the presence of family members is known as family-witnessed resuscitation (FWR). The positive benefits of having family members present during resuscitation have been documented.

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Objective. To explore the perceptions of healthcare professionals regarding FWR in an intensive care unit (ICU) and an accident and emergency (A&E) unit in a hospital in Kigali, Rwanda.

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Methods. A qualitative approach was used to explore the participants' perceptions regarding FWR, using two semi-structured individual interviews conducted with each participant. The principle of saturation was applied, and a total of eight participants from two departments (ICU and A&E) in a hospital in Kigali were included in this study.

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Results. From the participants' responses at the beginning of the interview, it was evident that FWR was a new concept for them. The participants welcomed the idea by expressing their perceived benefits of FWR. They established that the hospital where the research was conducted did not have any policies or procedures currently in place, but felt that this practice might be beneficial to the families, the patient and the medical team. However, participants did raise various concerns related to the challenges of implementing the practice of FWR.

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Conclusion. FWR is not currently practised in Rwanda and a number of recommendations are suggested in an attempt to introduce this practice as an option for Rwandan families.

Objective. The objective of this study was to describe the effect of normal saline instillation (NSI) on cardiorespiratory parameters in intubated cardiothoracic patients.

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Methods. A comparative design was employed to meet the study objectives. Simple random sampling was used to assign patients to study groups, namely a research group (non-NSI) and a control group (NSI). The data-capturing tool was based on the literature review. Descriptive and comparative statistics were employed to analyse the data. Findings were assessed according to p<0.05.

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Results. Findings indicated that there were no statistically significant differences in heart rate, blood pressure, arterial partial pressure of oxygen (PaO2), arterial oxygen saturation as measured by blood gas analyser (SaO2) and serum bicarbonate level (HCO3^-) when NSI was used or not used during endotracheal suctioning (p=0.05). Statistically significant differences were found in pH and patient return rate to baseline arterial oxygen saturation as measured by pulse oximetry (SpO2) after 30 minutes of suctioning: 63.6% of patients in the NSI group failed to return to baseline SpO2 v. 37.5% of patients in the non-NSI group (X²p=0.035; Fisher's exact p=0.048). There was a decrease in pH when NSI was used during suctioning. Although these differences were statistically significant, clinically they were not significant.

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Conclusion. It can be concluded that NSI had no effect on cardiorespiratory parameters in intubated cardiothoracic patients. Even though the patient population was at high risk of haemodynamic disturbance and hypoxia during this manoeuvre, there was no meaningful clinical effect; however, the sample size was too small to establish safety.

Background. Intellivent-adaptive support ventilation (ASV) is a closed-loop, fully automatic method of mechanical ventilation. This advanced mode of ventilation adjusts ventilation and oxygenation parameters according to patient weight, lung function (as assessed by the ventilator) and continuous input of end-tidal carbon dioxide and oxygen saturation. Our study compares the efficacy of this new mode with ASV and synchronised intermittent mandatory ventilation (SIMV) modes.

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Methods. We conducted a within-group comparison of three modes of ventilation, ASV, Intellivent-ASV and SIMV, using a Hamilton S1 ventilator (Hamilton Medical, Switzerland). Subjects were ventilated for 2 hours on each mode, and at the end of each 2-hour period, parameters of ventilation and haemodynamics were measured.

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Results. Twenty subjects participated in this study. Their mean age was 67.3 years (range 22 - 82 years). The most common diagnosis at presentation was pneumonia (55%), followed by chronic obstructive pulmonary disease (16%) and acute respiratory distress syndrome (11%). Mean (standard deviation) levels of positive end-expiratory pressure (PEEP) were significantly higher in the Intellivent-ASV group (7.6 (5) v. 5.1 (2) and 5.2 (2) cm H2O in the ASV and SIMV groups, respectively (p<0.005). Fractional inspired concentration of oxygen (FiO2) was significantly lower in the Intellivent-ASV group (0.35 (0.7)) v. 0.41 (0.6) and 0.41 (0.6) for the ASV and SIMV groups, respectively (p<0.005). The mean spontaneous breathing rate in the Intellivent-ASV group was 8.6 (7.5) breaths per minute (b/min), significantly higher than in the ASV group (2.9 (5.7) b/min) and the SIMV group (2.4 (4.5) b/min) (p=0.002), while there was no difference in the total respiratory rate between the groups. There was no significant difference in haemodynamic parameters between the different ventilation modes. ASV tended to produce lower partial pressure of carbon dioxide (PCO2) levels than SIMV and Intellivent-ASV (p<0.05).

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Conclusions. Intellivent-ASV provided a significant reduction in the FiO2 with higher PEEP levels, but without haemodynamic detriment. Intellivent-ASV encouraged significantly more spontaneous breathing, which may translate to faster weaning. Further studies to examine this effect are warranted.