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- Volume 30, Issue 2, 2014
Southern African Journal of Critical Care - Volume 30, Issue 2, 2014
Volume 30, Issue 2, 2014
Author W.L. MichellSource: Southern African Journal of Critical Care 30 (2014) http://dx.doi.org/10.7196/SAJCC.221More Less
Endotracheal intubation for mechanical ventilation has a central role in the intensive care unit (ICU), but is associated with numerous complications. One serious - but largely preventable - complication is tracheal stenosis, secondary to excessive pressure in the cuff of the endotracheal or tracheostomy tube. The high pressure in the cuff compresses the mucosa against the rigid tracheal cartilage rings, resulting in mucosal damage and ischaemic necrosis. Fibrotic healing of this lesion leads to the gradual stenosis of a section of the trachea. Patients may present weeks to months after discharge from the ICU when obstruction in the trachea reaches a critical degree. Stenosis may also make subsequent intubation of the trachea impossible. Other complications of high cuff pressure (Pcuff ) range from frequent sore throat to rare but disastrous events such as tracheo-oesophageal fistula.
Source: Southern African Journal of Critical Care 30, pp 35 –40 (2014) http://dx.doi.org/10.7196/SAJCC.159More Less
Background. Most patients admitted to an intensive care unit (ICU) for mechanical ventilation require endotracheal intubation. Cuffed endotracheal tubes (ETTs) are utilised as they provide a better seal to facilitate ventilation and minimise aspiration. Complications due to overinflation or underinflation of the cuff may occur. Neither the frequency of intermittent cuff pressure (Pcuff ) measurement nor the advantage of continuous Pcuff monitoring has been clearly established.
Objective. To determine deviations in ETT Pcuff from the recommended range during the intervals between routine thrice-daily Pcuff measurements in adult ICU patients. Our key objective was to identify the extent and cause of ETT Pcuff changes during these intervals. In addition, we attempted to demonstrate the failure of routine thrice-daily Pcuff monitoring to detect the large variation in Pcuff of patients throughout the day.
Methods. This prospective, observational study was conducted in the King Edward VIII Hospital ICU, Durban, KwaZulu-Natal Province, South Africa. Ethical and institutional approval was obtained. Consent was obtained from patients' next of kin. Intermittent Pcuff was recorded using mechanical manometers, and continuous measurements using pressure transducers.
Results. Thirty-five critically ill adult patients were enrolled. The mean study time was 11.1 h. The mean Pcuff was 25.6 (standard deviation 7.1) cmH2O for the intermittent group and 26.6 (8.7) cmH2O for the continuous group. The intermittent pressure measurements were in the low-pressure range ((< 2lt;20 cmH2O) 12% of the time compared with 83% in the target pressure range (20 - 30 cmH2O) and 5% in the high-pressure range (>30 cmH2O). For continuous pressures, 13% of the time was spent in the low-pressure range, 64% in the target pressure range, and 23% in the high-pressure range. For the entire study, 588 events causing Pcuff alterations were recorded.
Conclusion. Continuous monitoring of Pcuff indicated that the endotracheal Pcuff varied extensively during mechanical ventilation in critically ill patients, such variation being noted both between patients and within individual patients. Variations in individual patients occurred both during intrinsic patient activities and those of ICU personnel as part of routine patient maintenance. Intermittent monitoring may not detect these variations. Continuous monitoring of Pcuff during mechanical ventilation in ICUs is thus recommended for all patients.
Source: Southern African Journal of Critical Care 30, pp 41 –44 (2014) http://dx.doi.org/10.7196/SAJCC.194More Less
Background. The role of the pharmacist has evolved over the last 2 decades beyond traditional functions such as stock control and dispensing.
Objectives. To describe the functions performed by a clinical pharmacist while based in a surgical and trauma intensive care unit of a teaching hospital.
Methods. An operational research study that included indications of programme success was conducted. Interventions to assess therapy and achieve definite outcomes to satisfy patients' medicine needs were documented for 51 patients over a study period of 8 weeks.
Results. A total of 181 interventions were suggested by the pharmacist, with 127 (70%) accepted and implemented by the medical and nursing staff of the unit. The most frequent interventions were related to: untreated medical conditions (15.5%), appropriate therapy or course (13.8%), investigations indicated or outstanding (12.2%), and inappropriate doses and dosing frequency (11%). Interventions were also made regularly to address system errors or non-compliance and factors hindering therapeutic effect. Of the 250 h the pharmacist spent in the ward, most time was used for pharmaceutical care (28%) and ward rounds (21%) with members of the multidisciplinary team.
Conclusions. The study results demonstrated that a clinical pharmacist's contribution to patient care at ward level resulted in improved monitoring of pharmacotherapy. Medicine-related problems were identified and addressed.
Source: Southern African Journal of Critical Care 30, pp 45 –50 (2014) http://dx.doi.org/10.7196/SAJCC.190More Less
Objective. To determine the prevalence of dysmagnesaemia among patients admitted to a trauma intensive care unit (ICU) and to investigate whether dysmagnesaemia at admission correlated with a worse outcome.
Methods. In this retrospective case study of patients admitted to a regional level 1 trauma unit, from April 2007 to November 2010, de-identified patient data were obtained from the local patient database. Patients were divided into three groups (hypomagnesaemic, normomagnesaemic and hypermagnesaemic), which in turn were divided into two subgroups (blunt and penetrating trauma). The mortality between normo- and hypomagnesaemic patients, as well as between the subgroups, was analysed using X2 tests. The University of KwaZulu-Natal Biomedical Research Ethics Committee approved the study (BE207/09).
Results. Of the 759 trauma patients studied, 10.7% were hypomagnesaemic and 1.3% were hypermagnesaemic at admission. No statistically significant difference in mortality was observed between the hypo- and normo-/hypermagnesaemic patients.
Conclusion. Dysmagnesaemia is common among trauma patients admitted to the ICU, but is not necessarily correlated with a poorer outcome.
Source: Southern African Journal of Critical Care 30, pp 50 –54 (2014) http://dx.doi.org/10.7196/SAJCC.188More Less
Background. Nurses are primary caregivers and have a key role in providing care in a culturally diverse healthcare system, such as in South Africa (SA). Nurses need cultural competence in the management of patients within this cultural context. A healthcare system staffed by a culturally competent workforce can provide high-quality care to diverse population groups, contributing to the elimination of health disparities.
Objective. To describe the self-rated levels of cultural competence of nurses working in critical care settings in a selected public hospital in SA.
Methods. A quantitative descriptive survey was conducted with nurses from eight critical care units in a public hospital in KwaZulu-Natal Province, using the Inventory to Access the Process of Cultural Competency - Revised (IAPCC-R) cultural competence questionnaire.
Results. The overall cultural competence score for the respondents was 70.2 (standard deviation 7.2) out of a possible 100, with 77 (74%) of the respondents scoring in the awareness range, 26 (25%) in the competent range, and only 1 in the proficient range. Nurses from non-English-speaking backgrounds scored significantly higher in cultural competence than English-speaking nurses.
Conclusion. In addressing the many faces of cultural diversity, healthcare professionals must realise that these faces share a common vision: to obtain quality healthcare services that are culturally responsive and culturally relevant to the specific cultural group.
Source: Southern African Journal of Critical Care 30, pp 55 –57 (2014) http://dx.doi.org/10.7196/SAJCC.193More Less
Background. The accurate assessment of fluid balance data collected during physical assessment as well as during monitoring and record-keeping forms an essential part of the baseline patient information that guides medical and nursing interventions aimed at achieving physiological stability in patients. An informal audit of 24-hour fluid balance records in a local intensive care unit (ICU) showed that seven out of ten fluid balance calculations were incorrect.
Objective. To identify and describe current clinical nursing practice in fluid balance monitoring and measurement accuracy in ICUs, conducted as part of a broader study in partial fulfilment of a Master of Nursing degree.
Methods. A quantitative approach utilising a descriptive, exploratory study design was applied. An audit of 103 ICU records was conducted to establish the current practices and accuracy in recording of fluid balance monitoring. Data were collected using a purpose-designed tool based on relevant literature and practice experience.
Results. Of the original recorded fluid balance calculations, 79% deviated by more than 50 mL from the audited calculations. Furthermore, a significant relationship was shown between inaccurate fluid balance calculation and administration of diuretics (p=0.01).
Conclusion. The majority of fluid balance records were incorrectly calculated.
Source: Southern African Journal of Critical Care 30 (2014) http://dx.doi.org/10.7196/SAJCC.195More Less
Seldinger's technique is widely used to place central venous and arterial catheters, and is generally considered to be safe. The technique does, however, have multiple potential risks. Guidewire-related complications are rare but potentially serious. We describe a case of a lost guidewire during central venous catheter insertion followed by retrieval by an interventional radiologist, and outline measures that can be taken to prevent such complications.
Scientific presentations to the Congress of the Critical Care Society of Southern Africa 2014 : abstractsSource: Southern African Journal of Critical Care 30, pp 59 –64 (2014) http://dx.doi.org/10.7196/SAJCC.219More Less