Anaesthesia and intensive care
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Anaesth Intensive Care · Mar 2015
Efficacy of the APACHE II score at ICU discharge in predicting post-ICU mortality and ICU readmission in critically ill surgical patients.
In this study, we evaluated the efficacy of the discharge Acute Physiology and Chronic Health Evaluation (APACHE) II score in predicting post-intensive care unit (ICU) mortality and ICU readmission during the same hospitalisation in a surgical ICU. Of 1190 patients who were admitted to the ICU and stayed >48 hours between October 2007 and March 2010, 23 (1.9%) died and 86 (7.2%) were readmitted after initial ICU discharge, with 26 (3.0%) admitted within 48 hours. The area under the receiver operating characteristics curve of the discharge and admission APACHE II scores in predicting in-hospital mortality was 0.631 (95% confidence interval [CI] 0.603 to 0.658) and 0.669 (95% CI 0.642 to 0.696), respectively (P=0.510). ⋯ The area under the receiver operating characteristics curve of discharge APACHE II score in predicting early ICU readmissions was, however, higher than that of admission APACHE II score (0.688 [95% CI 0.660 to 0.714] versus 0.505 [95% CI 0.476 to 0.534], P=0.001). The discharge APACHE II score (odds ratio [OR] 1.1, 95% CI 1.01 to 1.22, P=0.024), unplanned ICU readmission (OR 20.0, 95% CI 7.6 to 53.1, P=0.001), eosinopenia at ICU discharge (OR 6.0, 95% CI 1.34 to 26.9, P=0.019), and hospital length-of-stay before ICU admission (OR 1.02, 95% CI 1.01 to 1.03, P=0.021) were significant independent factors in predicting post-ICU mortality. This study suggests that the discharge APACHE II score may be useful in predicting post-ICU mortality and is superior to the admission APACHE II score in predicting early ICU readmission in surgical ICU patients.
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Anaesth Intensive Care · Mar 2015
The effects of haemodilution with albumin on coagulation in vitro as assessed by rotational thromboelastometry.
We investigated the in vitro viscoelastic changes of progressive haemodilution with 4% albumin compared with normal saline (NS) using rotational thromboelastometry (ROTEM(®), Pentapharm Co., Munich, Germany). Whole blood samples obtained from 20 healthy volunteers were diluted in vitro with 4% albumin or NS by 10%, 20% and 40%. Fibrinogen concentration and ROTEM(®) (EXTEM [screening test for the extrinsic haemostasis system], FIBTEM [EXTEM-based assay for the fibrin part of the clot]) variables including coagulation time, clot formation time (CFT), α-angle, maximum clot firmness and lysis index were measured in the undiluted sample and at each degree of haemodilution. ⋯ A significant decrease in maximum clot firmness from undiluted measurements (P=0.05) was observed at lower haemodilutions with albumin (20% with EXTEM, 10% with FIBTEM) compared with NS (40% with EXTEM and FIBTEM). The adverse effects of large degrees of haemodilution with 4% albumin solution are in excess of what can be explained by haemodilution alone. This study suggests that large degrees of haemodilution with albumin impair fibrinogen activity to a greater extent than equivalent degrees of haemodilution with NS.
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Anaesth Intensive Care · Mar 2015
The impact of a cadaver-based airway lab on critical care fellows' direct laryngoscopy skills.
This study sought to determine the impact of a cadaver-based airway lab on critical care medicine fellows' direct laryngoscopy skills and hypothesised that fellows can improve their self-reported percentage of glottic opening (POGO) scores in cadaver models to achieve POGO scores similar to that of expert faculty. Nineteen fellows attended an airway management skills laboratory utilising five modified cadavers. Initial fellow POGO (POGOi) visualised was recorded at the onset with direct laryngoscopy. ⋯ Clinical success rates of intubation were over 98%. A short training session using modified cadavers can be utilised to teach new critical care medicine fellows additional techniques for airway management and assist them in obtaining higher POGO scores, similar to those of expert instructors. Success rates of clinical intubations were favourable in the wake of this training.
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Anaesth Intensive Care · Mar 2015
Case ReportsMaternal pulmonary oedema during foetoscopic surgery.
We report a case of maternal pulmonary oedema necessitating intubation and ventilation with associated hyperchloraemic metabolic acidosis during foetoscopic laser surgery for twin-twin transfusion syndrome (TTTS), believed to be secondary to absorption of normal saline irrigation fluid. TTTS complicates 10% to 20% of monochorionic twin pregnancies and develops due to imbalanced vascular anastomoses and consequent unidirectional transfusion between the twins. The recipient is at risk of cardiac failure due to circulatory overload and the donor twin becomes hypoperfused. ⋯ Since the Eurofoetus study, laser ablation has been the mainstay of treatment for pre-viable TTTS, involving insertion of endoscopes transabdominally into the polyhydramniotic sac to allow visualisation and ablation of the anastosmotic vessels. Amnioreduction does not correct the underlying pathology and offers very little in advanced disease. Foetoscopic laser ablation leads to an improved survival past 28 days and a lower incidence of neurological complications compared to serial amnioreduction.
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Anaesth Intensive Care · Mar 2015
The epidemiology of sepsis during rapid response team reviews in a teaching hospital.
In a three-month retrospective study, we assessed the proportion of rapid response team (RRT) calls associated with systemic inflammatory response syndrome (SIRS) and sepsis. We also documented the site of infection (whether it was community- or hospital-acquired), antibiotic modifications after the call and in-hospital outcomes. Amongst 358 RRT calls, two or more SIRS criteria were present in 277 (77.4%). ⋯ Infection was hospital-acquired in 91 (57.2%) and community-acquired in 67 (42.1%) cases, respectively. Patients were on antibiotics in 127 of 159 (79.9%) cases before the RRT call and antibiotics were added or modified in 76 of 159 (47.8%) cases after RRT review. The hospital length-of-stay of patients who received an RRT call associated with sepsis was longer than those who did not (16.0 [8.0 to 28.5] versus 10 days [6.0 to 18.0]; P=0.002).