The Southern African journal of critical care : the official journal of the Critical Care Society最新文献

Background: Professional quality of life, measured as compassion satisfaction, is a prerequisite for nurses working in intensive care units where patients rely on their care. Nurses who experience compassion satisfaction, or good professional quality of life, engage enthusiastically with all work activities and render quality patient care. In contrast, compassion fatigue eventually leads to disengagement from work activities and unsatisfactory patient outcomes. In this study, we described the demographic factors influencing professional quality of life of intensive care nurses working in public hospitals in Gauteng, South Africa (SA), during the first wave of the COVID-19 pandemic.

Objectives: To describe the demographic factors associated with professional quality of life of critical care nurses working in Gauteng, SA.

Methods: In this cross-sectional study, we used total population sampling and invited all nurses who had worked for at least 1 year in one of the critical care units of three selected public hospitals in Gauteng to participate. One-hundred and fifty-four nurses responded and completed the ProQol-5 tool during the first wave of the COVID-19 pandemic. Data were analysed using descriptive and inferential statistics.

Results: The nurses' average age was 45 years, and 59.1% (n=91) had an additional qualification in critical care nursing. Most of the nurses had a diploma (51.3%; n=79), with a mean work experience of 12.56 years. The main demographic variables that influenced professional quality of life were years of work experience (p=0.047), nurses' education with specific reference to a bachelor's degree (p=0.006) and nurse-patient ratio (p<0.001).

Conclusion: Nurses working in critical care units in public hospitals in Gauteng experienced low to moderate compassion satisfaction, moderate to high burnout and secondary traumatic stress, suggesting compassion fatigue. The high workload, which may have been associated with the COVID-19 pandemic, influenced nurses' professional quality of life.

Contributions of the study: This study reports on the important problem of compassion fatigue and burnout amongst South African ICU nurses working in the public sector. Associated factors were identified, which should be addressed to improve nurses' wellbeing.

Background: A scoring system based on physiological conditions was developed in 1984 to assess the severity of illness. This version, and subsequent versions, were labelled Simplified Acute Physiology Scores (SAPS). Each extension addressed limitations in the earlier version, with the SAPS III model using a data-driven approach. However, the SAPS III model did not include data collected from the African continent, thereby limiting the generalisation of the results.

Objectives: To propose a scoring system for assessing severity of illness at intensive care unit (ICU) admission and a model for prediction of in-hospital mortality, based on the severity of illness score.

Methods: This is a prospective cohort study which included patients who were admitted to an ICU in a South African tertiary hospital in 2017. Logistic regression modelling was used to develop the proposed scoring system, and the proposed mortality prediction model.

Results: The study included 829 patients. Less than a quarter of patients (21.35%; n=177) died during the study period. The proposed model exhibited good calibration and excellent discrimination.

Conclusion: The proposed scoring system is able to assess severity of illness at ICU admission, while the proposed statistical model may be used in the prediction of in-hospital mortality.

Contributions of the study: This study is the first to develop a model similar to the SAPS III model, based on data collected in South Africa. In addition, this study provides a potential starting point for the development of a model that can be used nationally.

Background: The COVID-19 pandemic has had a significant impact on healthcare systems globally as most countries were not equipped to deal with the outbreak. To avoid complete collapse of intensive care units (ICUs) and health systems as a whole, containment measures had to be instituted. In South Africa (SA), the biggest intervention was the government-regulated national lockdown instituted in March 2020.

Objectives: To evaluate the effects of the implemented lockdown and institutional guidelines on the admission rate and profile of non-COVID-19 patients in a regional and tertiary level ICU in Pietermaritzburg, KwaZulu-Natal Province, SA.

Methods: A retrospective analysis of all non-COVID-19 admissions to Harry Gwala and Greys hospitals was performed over an 8-month period (1 December 2019 - 31 July 2020), which included 4 months prior to lockdown implementation and 4 months post lockdown.

Results: There were a total of 678 non-COVID-19 admissions over the 8-month period. The majority of the admissions were at Greys Hospital (52.4%; n=355) and the rest at Harry Gwala Hospital (47.6%; n=323). A change in spectrum of patients admitted was noted, with a significant decrease in trauma and burns admissions post lockdown implementation (from 34.2 - 24.6%; p=0.006). Conversely, there was a notable increase in non-COVID-19 medical admissions after lockdown regulations were implemented (20.1 - 31.3%; p<0.001). We hypothesised that this was due to the gap left by trauma patients in an already overburdened system.

Conclusion: Despite the implementation of a national lockdown and multiple institutional directives, there was no significant decrease in the total number of non-COVID-19 admissions to ICUs. There was, however, a notable change in spectrum of patients admitted, which may reflect a bias towards trauma admissions in the pre COVID-19 era.

Contributions of the study: We describe the impact of the COVID-19 pandemic on critical care services in a resource-limited setting. We also demonstrate the ongoing need for intensive care unit beds within the public sector.

Background: The characteristics and mortality outcomes of patients admitted to South African intensive care units (ICUs) owing to medical conditions are unknown. Available literature is derived from studies based on data from high-income countries.

Objectives: To determine ICU utilisation by medical patients and evaluate the scope of admissions and clinical associations with hospital mortality in ICU patients 12 years and older admitted to an Eastern Cape tertiary ICU, particularly in the subset with HIV disease.

Methods: A retrospective descriptive one-year cohort study. Data were obtained from the LivAKI study database and demographic data, comorbidities, diagnosis, and mortality outcomes and associations were determined.

Results: There were 261 (29.8%) medical ICU admissions. The mean age of the cohort was 40.2 years; 51.7% were female. When compared with the surgical emergencies, the medical subgroup had higher sequential organ failure assessment (SOFA) scores (median score 5 v. 4, respectively) and simplified acute physiology score III (SAPS 3) scores (median 52.7 v. 48.5), a higher incidence of acute respiratory distress syndrome (ARDS) (7.7% v. 2.9%) and required more frequent dialysis (20.3% v. 5.5%). Of the medical admissions, sepsis accounted for 32.4% of admission diagnoses. The HIV seroprevalence rate was 34.0%, of whom 57.4% were on antiretroviral therapy. ICU and hospital mortality rates were 11.1% and 21.5% respectively, while only acute kidney injury (AKI) and sepsis were independently associated with mortality. The HIV-positive subgroup had a higher burden of tuberculosis (TB), higher admission SOFA and SAPS 3 scores and required more organ support.

Conclusion: Among medical patients admitted to ICU, there was a high HIV seroprevalence with low uptake of antiretroviral therapy. Sepsis was the most frequently identified ICU admission diagnosis. Sepsis and AKI (not HIV) were independent predictors of mortality. Co-infection with HIV and TB was associated with increased mortality.

Contributions of the study: The epidemiology and outcomes of adults who are critically ill from medical conditions in South African intensive care units was previously unknown but has been described in this study. The association of sepsis, TB, HIV and acute kidney injury with mortality is discussed.

Background and objective: Critical care transport (CCT) involves the movement of critically ill patients between healthcare facilities. South Africa (SA), like other low- to middle-income countries, has a relative shortage of ICU beds, making CCT an inevitability. In SA, CCTs are mostly done by emergency care practitioners; however, it is unclear how universities offering Bachelor in Emergency Medical Care (BEMC) courses approach their teaching in critical care and whether the content taught is consistent between institutions. In our study we formally evaluate and compare the intensive and critical care transport modules offered at SA universities in their BEMC programmes.

Methods: The electronic version of curricula of the critical care transport modules from higher education institutes in SA offering the BEMC were subjected to document analysis. Qualitative (inductive content analysis) and quantitative (descriptive analysis) methods were used to describe and compare the different components of the curriculum. Curricula were assigned into components and sub-components according to accepted definitions of curricula. The components included: aims, goals, composition and objectives of the course; content or teaching material and work-integrated learning.

Results: The four universities that offer BEMC programmes were invited to participate, and three (75%) consented and provided data. The duration of the modules ranged from 6 to 12 months, corresponding with notional hours of 120 - 150. A total of 83 learning domains were generated from the coding process. These domains included content on mechanical ventilation, patient monitoring, arterial blood gases, infusions and fluid balance, and patient preparation and transfer. Two universities had identical structures and learning outcomes, while one had a different structure and outcomes; it corresponded with a 58% similarity. Clinical placements were in critical and emergency care units, operating theatres and prehospital clinical services.

Conclusion: In all components compared, the universities offering BEMC were more similar than they were different. It is unclear whether the components taught are relevant to the SA patient population and healthcare system context, or whether students are adequately prepared for clinical practice. Postgraduate educational programmes might need to be developed to equip emergency care practitioners to function in this environment safely.

Contributions of the study: Owing to the limited availability of ICU beds in South Africa, optimising and standardising critical care transport is an important consideration. This study identifies important elements for improving emergency medical care training in South Africa, as well as areas needing further research.

Background: Airway irritation caused by prolonged inflation of endotracheal tube (ETT) cuff results in post-intubation morbidities.

Objectives: We aimed to study intracuff lidocaine and alkalised lidocaine on sedation or analgesia requirements of patients undergoing mechanical ventilation in the intensive care unit (ICU). The primary outcome was to calculate the total dose of propofol and fentanyl required to obtund the unwanted airway and circulatory reflexes. Secondary outcomes were to determine the frequency and severity of cough and haemodynamic parameters.

Methods: It was a double-blinded, randomised controlled study in the ICU after emergency laparotomy, in patients aged 20 - 55 years, and classified as American Society of Anesthesiologists (ASA) classes 1E and 2E with tube in situ. Exclusion criteria were patients with body mass index >30 kg/m² , haemodynamic instability, requiring positive end-expiratory pressure ≥7 cm H₂O, and a history of chronic obstructive pulmonary disease. After ethics clearance and written consent, patients were randomly assigned into two groups (36 in each), Group L (ETT cuff inflated with lidocaine 2%) and Group AL (cuff inflated with a mixture of lidocaine 2% and sodium bicarbonate 1:1).

Results: Mean dose of propofol consumed in Group AL was significantly less than that in Group L (p<0.001). The mean standard deviation (SD) fentanyl utilisation in Group AL was 1 323.61 (187.27) µg, and that in Group L was 1433.09 (42.58) µg (p=0.040). Group L patients had a significantly higher incidence of cough than those in Group AL (p=0.01). There was no significant difference in the mean arterial pressure (p=0.22), although heart rate was significantly higher in Group L (p<0.001).

Conclusion: Alkalised lidocaine reduces the requirement of sedation, analgesia, and the incidence of cough in intubated patients maintaining haemodynamic stability when compared with lidocaine.

Contributions of the study: Alkalised lidocaine when used in endotracheal tube cuff inflation reduces the need for sedation and analgesia in mechanically-ventilated patients, and improves haemodynamic stability.

Background: Accidental intraoperative hypothermia is a common and avoidable adverse event of the perioperative period and is associated with detrimental effects on multiple organ systems and postoperative patient outcomes. In a resource-limited environment, prevention of intraoperative hypothermia is often challenging. Resourceful clinicians overcome these challenges through creative devices and frugal innovations.

Objectives: To investigate the thermal performance of two Baragwanath Rewarming Appliances (BaRA) against that of the Hotline device to describe an optimal setup for these devices.

Methods: This was a quasi-experimental laboratory study that measured the thermal performance of two BaRA devices and the Hotline device under a number of scenarios. Independent variables including fluid type, flow rate, warming temperature and warming transit distance were sequentially altered and temperatures measured along the fluid stream. Change in temperature (ΔT) was calculated as the difference between entry and exit temperature for each combination of variables for each warming device.

Results: A total of 219 experiments were performed. At a temperature of 43.0°C and a transit distance of 200 cm, the BaRA A configuration either matched or exceeded the ΔT of the Hotline over all fluid type and flowrate combinations. The BaRA B configuration does not provide comparable thermal performance to the Hotline. Measured flowrates were noticeably slower than manufacturer-quoted values for all intravenous (IV) cannulae used.

Conclusion: A warm-water bath at 43.0°C with 200 cm of submerged IV tubing provides thermal performance comparable to the Hotline device, with all fluid type and flowrate combinations.

Contributions of the study: The present study provides an evidence-based method for warming intravenous fluid in resource-limited scenarios.

Background: Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings.

Objectives: The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality.

Methods: This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS.

Results: The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source.

Conclusion: Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes.

Contributions of the study: The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.

Summary: Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/).

Key points: Brain death and circulatory death are the accepted terms for defining death in the hospital context.Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met.The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation.Brain-death testing while on extra-corporeal membrane oxygenation is outlined.Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation.The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.