Sedation and Delirium in the Intensive Care Unit: An Australian and New Zealand Perspective

A survey was conducted to determine sedation and delirium practices in Australian and New Zealand intensive care units.

The survey was in two parts, comprising an online survey of reported sedation and delirium management (unit survey) and a collection of de-identified data about each patient in a unit at a given time on a specified day (patient snapshot survey). All intensive care units throughout Australia and New Zealand were invited by email to participate in the survey.

Twenty-three predominantly metropolitan, level III Australian and New Zealand intensive care units treating adult patients participated. Written sedation policies were in place in 48% of units, while an additional 44% of units reported having informal sedation policies. Seventy percent of units routinely used a sedation scale. In contrast, only 9% of units routinely used a delirium scale. Continuous intravenous infusion is the primary means of patient sedation (74% of units). While 30% of units reported routinely interrupting sedation, only 10% of sedated patients in the snapshot survey had had their sedation interrupted in the preceding 12 hours. Oversedation appears to be common (46% of patients with completed sedation scales). Use of neuromuscular blockade is low (10%) compared to other published studies. Midazolam and propofol were the most frequently used sedatives. The proportion of patients developing delirium was 21% of assessable patients. Failed and self-extubation rates were low: 3.2% and 0.5% respectively.

In Australian and New Zealand intensive care units, routine use of sedation scales is common but not universal, while routine delirium assessment is rare. The use of a sedation protocol is valuable and should be encouraged.

Replication of equid herpesvirus-1 (EHV-1) in the testes and epididymides of ponies and venereal shedding of infectious virus

Six Welsh Mountain pony colts were infected intranasally with the Ab4 isolate of EHV-1. Clinical and virological monitoring demonstrated mild upper respiratory tract disease, with nasal shedding of virus and establishment of a cell-associated viraemia. Detailed pathological examination of the urogenital tract was performed post mortem on days 4-9 post-infection (PI). EHV-1 was isolated from the epididymis on day 8 and the testis on day 9 PI, with viral replication in endothelial cells of these organs and an associated necrotizing vasculitis and thrombosis. Productive viral infection of germinal epithelium was not observed. In a further study, three Welsh Mountain pony stallions were infected intranasally with Ab4, which again resulted in mild upper respiratory tract disease and the establishment of a cell-associated viraemia. Semen samples were collected up to day 60 PI. Two stallions showed a decrease in the proportion of morphologically normal sperm. Significant numbers of inflammatory cells were observed in the sperm-rich fraction of ejaculates collected from one stallion between days 16 and 28 PI; infectious virus was recovered from the semen of this animal between days 17 and 25 PI, after the cessation of viraemia. The affected stallion appeared clinically normal over the period of venereal EHV-1 shedding.

Replication of equid herpesvirus-1 in the vaginal tunics of colts following local inoculation

Equid herpesvirus-1 (EHV-1; Ab4 isolate) was inoculated unilaterally into the cavum vaginale of four pony colts under general anaesthesia. The animals were monitored daily for evidence of scrotal or testicular swelling and euthanased electively on days 3, 4, 6 and 12 after infection. Detailed pathological examination of the male genital tract was carried out. In animals examined at days 3 and 4 after infection, replication of EHV-1 was detected bilaterally in mesothelial and endothelial cells of the parietal and visceral vaginal tunics. The mesothelial infection had resolved by day 12 after infection, with no evidence of direct extension to deeper genital organs. None of the four colts showed significant scrotal or testicular swelling.

Acrosome reaction of stallion spermatozoa evaluated with monoclonal antibody and zona-free hamster eggs

The acrosome of the stallion spermatozoon was visualized by indirect immunofluorescence with monoclonal antibody (18.6) which recognized an integral acrosomal membrane component. Localization was confirmed by electron microscopy using peroxidase labelled antibody. In fresh semen samples (n = 19), 73.9 +/- 9.1% of the spermatozoa from five fertile stallions displayed a uniform bright fluorescence over their acrosome region. In two semen samples from an infertile stallion only 28% and 35% of spermatozoa showed the same pattern of fluorescence. Spermatozoa from fertile stallions incubated for up to 12 hours in TALP medium maintained motility and exhibited a significant progressive loss of acrosomes as detected by immunofluorescence. Alternatively, a similar loss of acrosomes could be induced with calcium ionophore A23187 over a 90 minute incubation. Ultrastructural observations and incubation with zona-free hamster eggs indicated that only with ionophore treatment was immunofluorescent acrosome loss correlated with a physiological acrosome reaction, while prolonged sperm incubation led to degenerative membrane changes. It was concluded that, if carefully validated, immunofluorescent localization of the acrosome of stallion sperm with monoclonal antibody could be used to monitor the acrosome reaction. Furthermore, definitive acrosome visualization would be valuable in assessing semen quality.

In vitro fertilization of horse follicular oocytes matured in vitro

In vitro fertilizing ability of stallion spermatozoa was assessed using horse follicular oocytes matured in vitro. After collection, stallion spermatozoa were either: 1) washed and incubated in TALP medium with 3 mg/ml bovine serum albumin (BSA) and 10 micrograms/ml heparin for 4h, 2) washed and incubated in TALP with 3 mg/ml BSA for 3 h and cultured for a further 1 h with 1 mM caffeine and 5 mM dbcAMP, 3) washed and incubated in TALP medium with 3 mg/ml BSA at pH 7.9-8.2 for 2-4 h, or 4) diluted and incubated in TALP medium with 10 mg/ml BSA and 7.14 microM calcium ionophore A 23187 for 5-10 min followed by washing. After a given pretreatment, suspensions were diluted into B2 medium to a concentration of 5 x 10(6) sperm/ml and co-incubated with oocytes for 12 h or 24-48 h. In the ionophore-treated group, 18 of 54 oocytes (33%) were fertilized by 12 h, and 11 of 45 (24%) cleaved by 24-48 h. Evidence of fertilization was not found in the oocytes incubated with spermatozoa from other treatment procedures.

Successful transfer of the embryos of Przewalski's horses (Equus przewalskii) and Grant's zebra (E. burchelli) to domestic mares (E. caballus)

Blastocysts were collected non-surgically from 2 Przewalski's horse and 2 Grant's zebra mares and transferred extra-specifically to domestic horse and donkey recipients. Nine Przewalski's horse embryos were transferred surgically, and 2 non-surgically, to domestic Welsh-type pony mares. After surgical transfer, 7 (77.8%) pregnancies were established and 4 foals were born. Twelve Grant's zebra embryos were transferred surgically to 5 pony and 7 domestic donkey recipients respectively and 1 non-surgically to a donkey; 3 (60%) zebra-in-horse pregnancies were established and 2 went to term. Only 2 (28.6%) zebra-in-donkey pregnancies were established but neither went to term, although one zebra foal was aborted alive at Day 292 but failed to survive. No pregnancies resulted from the non-surgical transfers. Measurement of chorionic gonadotrophin concentrations and parental-specific lymphocytotoxic antibodies in the serum of the recipient animals indicated a pronounced maternal immunological response to the extra-specific embryo, but this could not be correlated with success or failure of pregnancy. The results indicate that extra-specific embryo transfer may be a useful aid to breeding exotic equids in captivity.

Deep freezing of horse embryos

Fourteen horse embryos recovered non-surgically on Days 6-8 after ovulation (Day 0) were cooled slowly to - 35 degrees C (7 embryos) or - 40 degrees C (7 embryos) and stored in liquid nitrogen (- 196 degrees C) for 4-98 days. Surgical transfer of the thawed embryos to unmated recipient mares that had ovulated - 2 to + 1 days with respect to the embryo donors resulted initially in the establishment of 4 conceptuses. However, only one mare maintained her pregnancy to term.