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- Southern African Journal of Critical Care
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- Volume 31, Issue 2, 2015
Southern African Journal of Critical Care - Volume 31, Issue 2, 2015
Volume 31, Issue 2, 2015
Author B MorrowSource: Southern African Journal of Critical Care 31 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.249More Less
Ethical lapses are almost never a case of bad people, doing bad things, for no good reason. More often they are good people, doing bad things, for good reasons. (Marcia Angell, previous Editor-in-Chief (1988 - 2000), New England Journal of Medicine.)
Critical illness carries high morbidity and mortality worldwide, with a disproportionate burden of critical illness in low- and middle-income countries, where access to intensive care is particularly limited. Without research in the intensive care unit (ICU) population, we are unlikely to improve our understanding of how to safely and effectively manage a wide range of diseases and injuries, minimise discomfort, reduce organ dysfunction, improve survival, improve quality of life in survivors of critical illness, and ensure rational and equitable use of scarce resources. Clinical research in the critical care environment is therefore essential to inform best practice ('evidence-based care').
Source: Southern African Journal of Critical Care 31, pp 36 –41 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.235More Less
Background. Moral distress is experienced when nurses experience conflict while making an ethical decision. This is magnified when the decisions are about withholding or withdrawing life-sustaining treatment.
Objective. To explore and describe nurses' experiences of situations that involve end-of-life care and evoke moral distress in the intensive care units (ICUs) of two public tertiary-level hospitals in South Africa (SA), the personal consequences of these situations and the means employed to manage their distress.
Methods. An exploratory, descriptive design was used. A short survey/interview guide was administered to registered and enrolled nurses (N=100) employed in the ICUs from two academic-affiliated, specialist public hospitals.
Results. A total of 65 completed surveys were collected. Of these, 32 responses were judged not to be describing moral distress while33 clearly described moral distress and were included and analysed by means of initial content analysis. The findings were presented in five major categories: (i) collegial incompetence or inexperience; (ii) resource constraints; (iii) end-of-life issues; (iv) lack of consultation, communication and negotiation; and (v) support.
Conclusion. The study found that nurses experienced considerable moral distress. This is compounded in an environment where gender, professional and social status inhibit the nurses' assertiveness, 'voice' and influence in the healthcare system. Parallels can bedrawn between the microcosm of the ICU and the macrocosm of the SA social and ethical character.
Nutrition support practices in South African ICUs : results from a nationwide pilot survey : articleAuthor L.T. HillSource: Southern African Journal of Critical Care 31, pp 42 –50 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.252More Less
Background. Nutrition support of the critically ill can positively affect clinical outcomes. International audit data of nutrition practices in intensive care units (ICUs) suggest that inconsistent application of recommended nutrition support practices (NSPs) occurs. There are no data on NSPs in South African (SA) ICUs.
Objective. To perform a national pilot survey of NSPs in private SA adult ICUs.
Methods. A descriptive, observational, cross-sectional survey was performed among prescribers of nutrition support in private ICU facilities. Participants were targeted through non-randomised convenience sampling and invited to complete a 51-item electronic questionnaire covering ICU demographics, profile of nutrition prescribers, and nutrition assessment support, delivery and monitoring practices.
Results. Responses were received from 125 practitioners in 60% of representative private hospitals with ICU facilities, mainly general/ mixed ICUs. Forty-six percent of respondents reported structured nutrition support teams and 61% reported that practices were governed by formal nutrition support protocols. Enteral nutrition was reported to be based upon published guidelines by 72% of dietitians, while parenteral nutrition decisions were reportedly based mainly on clinical judgement (43%). For both enteral and parenteral feeding practices, compliance with guidelines was inconsistent. There was a disjuncture between various NSPs as reported by dietitians and by nurses. Nurses generally appeared unaware of published nutrition guidelines.
Conclusion. Various disparities in reported nutrition practices were revealed, suggesting that the organisation and operations of teams and the implementation of protocols informed by published nutrition guidelines may not be well established in private SA ICUs.
Comparison of the efficacy of colistin monotherapy and colistin combination therapies in the treatment of nosocomial pneumonia and ventilator-associated pneumonia caused by Acinetobacter baumannii : articleSource: Southern African Journal of Critical Care 31, pp 51 –58 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.246More Less
Objective. To investigate whether there was a difference in mortality, clinical response and bacterial eradication between colistin monotherapy and colistin combination therapies for the treatment of nosocomial pneumonia/ventilator-associated pneumonia (VAP)caused by Acinetobacter baumannii in a medical intensive care unit (ICU).
Methods. This retrospective, observational and single-centre study included all patients who were in the medical ICU of Gazi University Medical Faculty Hospital and diagnosed with nosocomial pneumonia/VAP caused by A. baumannii between January 2009 and September 2014.
Results. The median age of the 134 patients was 68 years and 53.3% were male. The most common causes of admission were respiratory insufficiency (66.7%) and sepsis/septic shock (54.8%). In patients with nosocomial pneumonia/VAP caused by A. baumannii, on median day 5 of admission, colistin monotherapy was used in 23 (21.6%) patients, a carbapenem combination was used in 80 (59.7%) patients, sulbactam-ampicillin combination was used in 42 (31.4%) patients, tigecycline combination was used in 26 (19.4%) patients, and sulbactam-cefoperazone combination was used in 17 (12.7%) patients. Median ICU stay of the patients was 15.5 days, and 112 (83.6%) patients died. Colistin monotherapy and combination therapies had no superiority over each other in clinical response for the treatment of A. baumannii-associated nosocomial pneumonia/VAP. Mortality was found to be higher in patients receiving the colistin-carbapenem combination (64.3% v. 36.4%, p=0.016). Discharge/day-of-death Sequential Organ Failure Assessment score (odds ratio (OR) 2.017, 95% confidence interval (CI) 1.330 - 3.061) and vasopressor use (OR 9.014, 95% CI 1.360 - 59.464) were independent risk factors for ICU mortality.
Conclusion. Colistin monotherapy and combination therapies have no superiority over each other for clinical response in the treatment of nosocomial pneumonia/VAP caused by multidrug-resistant A. baumannii. Colistin-SAM was associated with improved microbiological eradication and colistin-carbapenem combination was associated with increased mortality.
Source: Southern African Journal of Critical Care 31, pp 58 –61 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.247More Less
Background. Stroke is a potentially life-threatening, time-dependent event that requires urgent management to reduce morbidity and mortality. It has been suggested that earlier recognition by ambulance personnel and transport to stroke centres may significantly reduce treatment delays. For this reason it is vitally important that ambulance personnel are able to accurately diagnose stroke.
Methods. A series of vignettes were created that included images, video and audio displaying either signs or symptoms of stroke or those of another condition. Ambulance personnel were asked to review each vignette and state whether the patient described was suffering from a stroke or not. Further investigation was sought by requesting each individual to motivate their answer, mentioning upon what their diagnosis was based.
Results. A total of 40 basic life support (BLS) and intermediate life support (ILS) personnel from different sites diagnosed 280 vignettes. BLS personnel were able to diagnose stroke with a sensitivity of 85.3% and a specificity of 89.9% (positive predictive value (PPV) 86.7%, negative predictive value (NPV) 88.8%), while ILS achieved a sensitivity of 98.2% and specificity of 94.0% (PPV 91.7%, NPV 98.8%). The combined sensitivity and specificity were 91.5% and 92.0%, respectively (PPV 89.2%, NPV 93.8%). In order to aid their diagnosis, only5% of BLS and 18.34% of ILS utilised validated stroke screening tools.
Conclusion. Despite not using validated screening tools, the ambulance personnel sampled in this study were able to identify stroke with high accuracy. Further studies should be considered to identify how these diagnoses were reached in order to identify training needs.
Atrial myxoma-related embolism resulting in acute limb ischaemia in a critical care patient : case reportSource: Southern African Journal of Critical Care 31, pp 62 –63 (2015) http://dx.doi.org/http://dx.doi.org/10.7196/SAJCC.2015.v31i2.233More Less
This report presents an unusual case of limb ischaemia in the critical care setting, the cause of which was elucidated on echocardiography. Evaluation of the case highlights the importance of appropriate and timely investigation, in particular the role of bedside echocardiography. Although atrial myxomas are uncommon, a thorough investigation of patients presenting with acute peripheral ischaemic events should be undertaken to facilitate the diagnosis of this treatable condition.
Cardiopulmonary physiotherapy intrauma : an Evidence-based approach, Heleen van Aswegen and Brenda Morrow (eds.) : book reviewAuthor Alison Lupton SmithSource: Southern African Journal of Critical Care 31 (2015)More Less
Trauma is one of the leading causes of mortality and morbidity worldwide, affecting both adult and paediatric populations. The objective of this book is to provide physiotherapists at all stages of their careers with current evidence-based information to guide their physiotherapeutic management of both adults and children with trauma-related injuries. Information has been drawn from published research as well as the clinical expertise of the contributors to provide readers with a comprehensive book that details the physiotherapist's role and management of trauma related injuries.