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

Background: In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector.

Purpose: The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care.

Recommendations: In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years.

Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

Background: Internationally, the declining number of organ donors does not meet the rising demand for life-saving solid organ transplant operations. Critical care professional nurses play an important role in the identification of organ donors. A deeper understanding is needed of the missed opportunities of identification and referral of potential organ donors to organ transplant co-ordinators in the critical care environment.

Objectives: To describe the knowledge and views of critical care professional nurses (CCPNs) in South Africa concerning the early identification and referral of organ donors, and to describe the short-term effect of implementing a PowerPoint training intervention on nurses' knowledge in this domain.

Methods: A mixed method, experimental, exploratory, descriptive study design was followed. Critical care professional nurses in seven intensive care units at five private hospitals completed a data collection instrument comprising 11 quantitative and three qualitative questions, before and after completing a PowerPoint training intervention. The post test was done directly after the training intervention due to the environment of nursing shift work.

Results: A total of 173 (79%) CCPNs participated, from a population of 218. The median (interquartile range) score for all participants increased from 60% (48 - 76) prior to the PowerPoint training intervention, to 96% (88 - 96) after the intervention (p<0.0001). Three main themes emerged from the qualitative questions: stress experienced by the CCPNs during the organ donor process (62%); inadequate collaboration between doctors and nurses (34%); and the need for a policy (9%) to guide the donor referral process.

Conclusion: CCPNs' knowledge regarding the early identification and referral of potential organ donors increased significantly following a targeted PowerPoint training intervention. The identified themes suggest that CCPNs require support in order to effectively communicate with the donor's family and medical staff.

Contributions of the study: The findings of this study will contribute to the increase in organ donor referrals. Increased education of critical care professional nurses and doctors on effective communication, and the early identification and referral of organ donors, will expectedly help to resolve the critical barriers in the organ donor process.

Summary: Acute coronary syndromes due to coronary artery vasospasm occur rarely and are difficult to diagnose in the acute setting. We present a patient with hypocalcaemia-induced coronary artery vasospasm, which resulted in an acute ST-elevation myocardial infarction. This was reversible upon administering intravenous calcium, with no long-term cardiac consequences for our patient.

Contributions of the study: Hypocalcaemia is a common clinical problem that is usually clinically quiescent, but in the acute setting can present with dramatic signs and symptomsHypocalcaemia resulting in an acute coronary syndrome is usually rapidly reversed by administering intravenous calcium.A hypocalcaemia-induced acute coronary syndrome is most likely a function of the myocardium being perfused primarily during diastole, with partial vasospasm limiting the diastolic flow during times of increased cardiac output or energy requirements.

Background: Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients.

Objectives: To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith.

Methods: The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death).

Results: The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia.

Conclusion: The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management.

Contributions of the study: The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.

Background: The internal surfaces of pulse oximeter probes may be overlooked as hot spots for pathogenic microorganisms in an intensive care unit (ICU), thereby contributing to the high incidence of hospital-acquired infections.

Objectives: To determine the growth and identification of microorganisms on pulse oximeter probes in the multidisciplinary ICU (MICU) at Charlotte Maxeke Johannesburg Academic Hospital and the burns ICU (BICU) at Chris Hani Baragwanath Academic Hospital, before and after decontamination.

Methods: This was a cross-sectional, comparative and contextual study, using purposive sampling. Data were collected from the internal surfaces of 34 pulse oximeter probes in a MICU and BICU. Each pulse oximeter probe was swabbed before and after decontamination. The endemic microorganism profile for the two ICUs was obtained from a laboratory database.

Results: Internal surfaces of 31 (91%; 95% confidence interval (CI) 0.76 - 0.98) pulse oximeter probes were contaminated with 9 different pathogenic microorganisms pre decontamination. Acinetobacter baumannii, Klebsiella pneumoniaei and Pseudomonas aeruginosa were endemic to both ICUs, and were the most-frequently isolated microorganisms. Staphylococcus aureus was the most common microorganism endemic to both ICUs, isolated on the internal surfaces of only 2 pulse oximeter probes. Of the internal surfaces of pulse oximeter probes, 6 (18%; 95% CI 0.07 - 0.35) remained contaminated post decontamination, with a microorganism growth reduction of 80% (p=0.0001).

Conclusion: The internal surfaces of pulse oximeter probes may serve as hot spots for an array of pathogens with the potential to cause infection and outbreaks in ICUs. Decontamination of the internal surfaces of pulse oximeter probes should be emphasised.

Contributions of the study: This study identifies internal surfaces of pulse oximeter probes as reservoirs for infection in intensive care units (ICUs), particularly in a burns ICU setting, pinpointing one of many sources of hospital-acquired infections within ICU cubicles.The study emphasises the need to clean the internal surfaces of pulse oximeter probes (whether visibly soiled or not) prior to disinfection.

Background: There are limited South African data on the outcomes of patients with severe malaria treated with quinine compared with those treated with artesunate in the intensive care unit (ICU).

Objectives: To compare the outcomes of adult patients treated with artesunate against those treated with quinine in the ICU. Primary outcome variables are length of stay (LOS) in the ICU and mortality. Secondary outcomes include the incidence of hypoglycaemic episodes and neurological outcomes.

Methods: This was a retrospective cohort study of patients with severe malaria treated at a multidisciplinary ICU with artesunate or quinine from 1 January 2008 to 31 December 2012.

Results: Of the 92 patients included in the study, 63 (69.2%) were male. The mean age in the quinine and artesunate groups was 36.2 years and 40.5 years, respectively (p=0.071). Most (98.6%) of the patients with a positive travel history had visited a malaria-endemic region. Of the 53 patients tested for HIV infection, 71.7% tested positive (p=0.520). The average CD4+ cell count of HIV-positive patients treated with quinine was 200 cells/µL compared with 217.17 cells/µL for those treated with artesunate (p=0.875). The mean APACHE II score at admission was 20.85 and 19.62 in the quinine group and artesunate group, respectively (p=0.380). The median LOS was 5 days (range 1 - 27). Mortality was 15.4% in the quinine group and 7.7% in the artesunate group (p=0.246).

Conclusion: A statistically insignificant mortality difference was observed in outcomes of the two treatment groups in this retrospective, single-centre cohort study.

Contributions of the study: Intravenous artesunate is currently the preferred treatment in the management of patients with severe malaria. However, there are limited local data on the outcomes of artesunate v. quinine therapy for the management of severe malaria in highly monitored clinical environments in non-endemic regions of South Africa.We describe clinical characteristics, management and outcomes of patients with severe malaria treated with quinine and those treated with artesunate in the ICU in a non-endemic region.

Background: The critical illness of a loved one can negatively affect all family members (FMs), leading to the interruption of family functioning and integrity. Hospitalisation is a stressful, unplanned event for both the patient and FMs and is associated with psychological disturbances, emotional distress and altered family roles and functioning.

Objectives: To develop a theory of family care in critical care units (CCUs) for the South African setting.

Methods: Grounded theory, based on Strauss and Corbin's school of thought, was used. Audio-recorded in-depth interviews were conducted with 32 participants (9 FMs, 17 critical care nurses and 6 doctors) at a private hospital (3 CCUs) and a state hospital (10 CCUs). Data analysis involved open, axial and selective coding.

Results: The theory of family care during critical illness was identified. The core concept of the theory is empowerment, informed by the underlying constructs of information sharing, proximity, garnering resources, and cultural and religious cooperation.

Conclusion: The concepts of this theory can equip healthcare professionals in CCUs to provide appropriate family care for meeting the needs of patients' FMs and, in so doing, contribute to families having a more manageable critical care experience during the illness of their loved one.

Contributions of the study: This study adds to the limited body of knowledge regarding family care within the South African context. The study provides a theory to promote therapeutic partnerships between health care professionals, patients and FMs that will provide support for both the patient and FMs.It is further anticipated that the findings of the study will contribute not only to nurses' critical care curriculum, which currently includes very limited family support content, but also be helpful to doctors working in intensive care units.

Background: Rapid sequence intubation (RSI) involves inducing unconsciousness and paralysis in rapid succession in order to facilitate endotracheal tube placement. RSI has recently been introduced to the scope of practice of South African prehospital emergency care practitioners (ECPs). Despite this, there remains limited evidence supporting the efficacy and safety of RSI within this context. While in-hospital studies have shown that it can take 20 minutes or more to perform an RSI, little is known about the time taken to perform the procedure in the prehospital setting.

Objectives: To measure the time taken to perform an RSI in a simulated prehospital environment.

Methods: A sample of final-year ECP students were video-recorded performing RSIs on a mannequin within a simulated prehospital environment. Data were gathered through an analysis of the recordings, allowing for the capturing of times taken to complete each of the phases of a RSI.

Results: A mean time of 15 minutes 5 seconds was recorded to complete the procedure. This was shorter than times reported for in-hospital studies.

Conclusion: RSI is a potentially harmful procedure if improperly performed and has the potential to create delays in transport that may not always be in the patient's best interest. With a mean time of 15 minutes 5 seconds, the performance of RSI by ECP students in the simulated prehospital environment was faster than expected. Further research is recommended to explore the relationship between the performances observed in this mannequin-based study with those in authentic prehospital settings.

Contributions of the study: This study adds to a currently limited body of knowledge surrounding the performance of out-of-hospital anaesthesia by emergency care practitioners in the African context. The study highlights the fact that while prehospital rapid sequence intubation may be a lifesaving procedure, anaesthetising patients in an uncontrolled prehospital environment is not without risk. An important consideration that needs to be taken into account when making a decision on whether or not to perform the procedure within the prehospital setting is the potential delay this might have on transport time and arrival at the receiving facility.

Background: High-frequency oscillatory ventilation (HFOV) remains an option for the management of critically ill children when conventional mechanical ventilation fails. However, its use is not widespread, and there is wide variability reported with respect to how it is used.

Objectives: To describe the frequency, indications, settings and outcomes of HFOV use among paediatric patients with a primary respiratory disorder admitted to a tertiary paediatric intensive care unit (PICU).

Methods: The study was a 2-year, single-centre, retrospective chart review.

Results: Thirty-four (32.7%) patients were managed with HFOV in the PICU during the study period. Thirty-three of the 34 patients had paediatric acute respiratory distress syndrome. Indications for HFOV were inadequate oxygenation in 17 patients (50%), and refractory respiratory acidosis in 15 patients (44.1%) (2 patients did not fit into either category). Approaches to the setting of HFOV varied considerably, particularly with respect to initial pressure around the airways. HFOV was effective at improving both oxygenation, with a median (interquartile range (IQR)) decrease in oxygenation index of 6.34 (5.0 - 9.5), and ventilation with a the median decrease in PaCO₂ of 67.6 (46.2 - 105.7) mmHg after 24 hours. Overall mortality was 29.4% in the HFOV group, which is consistent with other studies.

Conclusion: HFOV remains an effective rescue ventilatory strategy, which resulted in rapid and sustained improvement in gas exchange in patients with severe hypoxaemia and/or severe respiratory acidosis, particularly in the absence of extracorporeal support. However, the variability in practice and the adverse effects described highlight the need for future high-quality randomised controlled trials to allow for development of meaningful guidelines to optimise HFOV use.

Contributions of the study: This study describes the use and outcomes of high-frequency oscillatory ventilation (HFOV) in a South African paediatric intensive care unit, thus addressing a local knowledge gap and providing evidence of the continued efficacy of HFOV for severe hypoxaemia and refractory respiratory acidosis in settings without access to extracorporeal technologies.