Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies

BACKGROUND

The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery.

METHODS

A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output.

RESULTS

Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations.

CONCLUSION

The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

Telephonic follow-up after day case pediatric surgery in an upper middle income country: A pilot study

BACKGROUND

One third of South African children live in households with no employed adult. Telemedicine may save patients and the strained public health sector significant resources. We aimed to determine the safety and benefits of telephonic post-operative follow-up of patients who presented for day case surgery at CHBAH from 1 January-31 March 2023.

METHODS

A prospective descriptive study on patients undergoing day case surgery was performed. Healthy patients greater than 6 years old whose caregivers spoke English and had access to a smartphone were included. Data on the total number of telephonic follow-ups, operative complications, need for in person review, satisfaction with telephonic follow-up, and savings in transport costs and time by avoiding in person follow-up were collected.

RESULTS

A total of 38 telephonic follow-ups were performed. Six (15.8%) patients presented for in person review due to the detection of major complications (2, 5.3%), minor complications (2, 5.3%), and parental concern (2, 5.3%) during telephonic follow-up. All caregivers reported being satisfied with telephonic follow-up. Total savings in transport costs were R4452 (US $ 248.45). The majority of patients (29, 76.3%) had at least one unemployed parent. Seven caregivers (18.4%) avoided taking paid leave and 2 (5.3%) unpaid leave from work due to follow-up being performed telephonically.

CONCLUSIONS

Innovation is necessary in order to expand access to safe, affordable, and timely care. In this selected group, telephonic follow-up was a safe, acceptable, and cost-effective intervention. The expansion of such a program has the potential for significant savings for patients and the healthcare system.

Peri-operative pharmacokinetics of cefazolin prophylaxis during valve replacement surgery

OBJECTIVE

There is little prospective data to guide effective dosing for antibiotic prophylaxis during surgery requiring cardiopulmonary bypass (CPB). We aim to describe the effects of CPB on the population pharmacokinetics (PK) of total and unbound concentrations of cefazolin and to recommend optimised dosing regimens.

METHODS

Patients undergoing CPB for elective cardiac valve replacement were included using convenience sampling. Intravenous cefazolin (2g) was administered pre-incision and re-dosed at 4 hours. Serial blood and urine samples were collected and analysed using validated chromatography. Population PK modelling and Monte-Carlo simulations were performed using Pmetrics® to determine the fractional target attainment (FTA) of achieving unbound concentrations exceeding pre-defined exposures against organisms known to cause surgical site infections for 100% of surgery (100% fT>MIC).

RESULTS

From the 16 included patients, 195 total and 64 unbound concentrations of cefazolin were obtained. A three-compartment linear population PK model best described the data. We observed that cefazolin 2g 4-hourly was insufficient to achieve the FTA of 100% fT>MIC for Staphylococcus aureus and Escherichia coli at serum creatinine concentrations ≤ 50 μmol/L and for Staphylococcus epidermidis at any of our simulated doses and serum creatinine concentrations. A dose of cefazolin 3g 4-hourly demonstrated >93% FTA for S. aureus and E. coli.

CONCLUSIONS

We found that cefazolin 2g 4-hourly was not able to maintain concentrations above the MIC for relevant pathogens in patients with low serum creatinine concentrations undergoing cardiac surgery with CPB. The simulations showed that optimised dosing is more likely with an increased dose and/or dosing frequency.

Carbon dioxide levels of ventilated adult critically ill post-operative patients on arrival at the intensive care unit

Background

The transportation of critically ill patients presents a precarious situation in which adverse events may occur. At Chris Hani Baragwanath Academic Hospital (CHBAH) patients were manually ventilated using a manual resuscitator bag during transportation from theatre to the intensive care unit (ICU).

Objectives

To evaluate the arterial partial pressure of carbon dioxide (PaCO₂ ) levels of ventilated adult critically ill post-operative patients on arrival at the ICU at CHBAH.

Methods

This was a cross-sectional study using convenience sampling. Pre- and post-transportation arterial blood gases were obtained from 47 patients.

Results

There was a statistically significant difference in the pre- and post-transport PaCO₂ level (p=0.03), with a mean difference of 3.3 mmHg. The pre- and post-transport arterial partial pressure of oxygen (PaO₂ ) level (p≤0.001) and the week and weekend pre-transport (p≤0.001) and post-transport (p=0.01) PaCO₂ were statistically significantly different. No statistically significant difference was found in the other arterial blood gas parameters or in the post-transport PaCO₂ of those patients (26 (55.3%)), who received a neuromuscular blocking drug compared with those that did not. Adverse events were noted during 12 (25.6%) of the transports, 5 (41.7%) of which were patient-related, and 7 (58.3%) of which were infrastructure-related.

Conclusion

There was a statistically but not clinically significant difference in the pre- and post-transport PaCO₂ level and between week and weekend transportations. Hypercarbia was the most common derangement in all transports. Adverse events occurred during one-quarter of transportations.

Contributions of the study

This study evaluated the PaCO₂ levels of critically ill patients at CHBAH during transportation from theatre to the ICU. The findings indicate that manual ventilation was not injurious. The authors recommend reproducing the study in patients with severe ARDS and pulmonary hypertension to ascertain if manual ventilation is safe in this population; and also with healthcare practitioners other than anaesthesiologists, who may not be as experienced in manual ventilation.

A Retrospective Review of Decision to Delivery Time Interval for Foetal Distress at a Central Hospital

PURPOSE

The aim of this study was to describe the trajectory of emergency caesarean deliveries for foetal distress at Chris Hani Baragwanath Academic Hospital (CHBAH).

PATIENTS AND METHODS

A retrospective, contextual, descriptive study, using consecutive convenience sampling was done reviewing all the records of emergency caesarean deliveries for foetal distress at CHBAH in February 2019 until a minimum sample size of 385 was reached.

RESULTS

During the study period, a total of 617 caesarean deliveries were done, of which 572 (92.7%) were emergencies. Foetal distress accounted for 395 (69.1%) of the emergency caesarean deliveries. No emergency caesarean delivery for foetal distress conformed to the 30-minute DDI and the mean (SD) DDI was 411 (291) minutes. The mean (SD) 5-minute and 10-minute Apgar scores were 8.4 (1.6) and 9.6 (1.3), respectively. There was a significant difference between the type of anaesthetic (general or neuraxial), with those receiving general anaesthesia having shorter anaesthetic start to cut time (p=0.0110). However, those delivered following neuraxial anaesthesia had better 5-minute (p=0.0002) and 10-minute (p=0.0175) Apgar scores.

CONCLUSION

This study showed that a DDI of 30-minutes, was not achieved at CHBAH during the study period. Most babies diagnosed with foetal distress pre-delivery had 5-minute and 10-minute Apgar scores inconsistent with this diagnosis. This over-diagnosis of foetal distress in some cases could have led to delays in delivery of babies who had actual foetal distress and where a 30-minute DDI could have improved outcome.

Erratum: Anaesthetists’ knowledge of airborne infections

No abstract available.

Anaesthetists’ knowledge of airborne infections

Background: Anaesthetists need to be knowledgeable regarding the control of airborne infection to ensure safe practice. The aim of this study was to determine anaesthetists’ knowledge regarding airborne infections in the perioperative period in the Department of Anaesthesiology at the University of the Witwatersrand.Methods: A cross-sectional research design was followed using an anonymous self-administered questionnaire. Data were collected at academic departmental meetings by convenience sampling. Returning the questionnaire implied consent. A score of 65% was considered adequate knowledge.Results: Of the 150 questionnaires distributed, 137 (91.3%) questionnaires were returned. An overall mean (standard deviation [s.d.]) score of 58.8% (4.252) was achieved, and only 11 (8.1%) of anaesthetists had adequate knowledge. There was no statistically significant association between seniority and passing or failing (p = 0.327). The highest mean (s.d.) score, 67.4% (6.979), was reported in the section pertaining to patients, followed by the section regarding operating theatre staff at 58.1% (11.899) and the lowest mark, 53.5% (5.553), for the environment section. Anaesthetists scored significantly better in the knowledge regarding patients’ section than in other sections (p  0.0005).Conclusion: Knowledge of airborne infections in this study was poor, with only 8.1% achieving a pass, and no difference in knowledge between junior and senior anaesthetists was observed. Considering the ongoing coronavirus disease 2019 (COVID-19) pandemic at the time of the study, this was a surprising finding. Urgent action needs to be taken to ensure the safety of anaesthetists, other operating theatre staff and patients. 

Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital

Background: The aim of this study was to determine the anti-factor Xa levels in patients receiving enoxaparin sodium for venous thromboembolism prophylaxis in the intensive care unit (ICU).

Patients and methods: Using a cross-sectional study methodology, 73 ICU patients receiving 40 mg enoxaparin sodium daily were enrolled in this study. Anti-factor Xa levels were measured following the second dose. Prophylactic and subprophylactic groups of patients were compared for age, sex, weight, body mass index, total bilirubin, serum albumin, and APACHE II score.

Results: Anti-factor Xa levels were prophylactic (0.2–0.6 IU/mL) in 44 (60.3%) patients and subprophylactic (<0.2 IU/mL) in 29 (39.7%) patients. The mean (SD) actual delivered dose of enoxaparin per kilogram body weight was significantly higher, at 0.59 (0.11) mg/kg in the prophylactic group compared to 0.53 (0.13) mg/kg in the subprophylactic group (p = 0.043). The subprophylactic group had significantly lower serum albumin levels compared to the prophylactic group. The total bilirubin levels were not found to be significantly different between the two groups (p = 0.110).

Conclusion: A fixed prophylactic 40 mg dose of enoxaparin was associated with a high proportion of subprophylactic anti-factor Xa levels. Weight-based dose and serum albumin level were independent predictors of achieving the prophylactic target range.

How to cite this article: Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021;25(8):917–919.

Microbial contamination of the hands of healthcare providers in the operating theatre of a central hospital

Background

Effort is invested in maintaining the sterility of the operating field, but less attention is paid to potential healthcare associated infection (HAI) sources through patient contact with non-scrubbed healthcare providers (HCPs). A single microbiological assessment of hands can provide a good assessment of the potential dynamic transmission of microorganisms. The aim of this study was to identify and quantify the microbial growth on the hands of HCPs in the operating theatres of Chris Hani Baragwanath Academic Hospital.

Methods

A prospective, contextual and descriptive study design was followed. Seventy-five samples were collected using convenience sampling from an equal number of surgeons, anaesthetists and nurses. Specimens were taken using agar plates and underwent semi-quantitative analysis.

Results

All the hands of the HCPs displayed growth; 95% grew commensals and 64% grew pathogens. Eighteen commensal microorganisms and 21 pathological microorganisms were noted. Comparisons of commensal, pathological and combined levels of contamination among the three groups were not statistically significant (p = 0.061, p = 0.481, p = 0.236). No significant difference between the growth of combined microorganisms (p = 0.634) and pathological microorganisms (p = 0.499) among the groups. Surgeons had significantly more commensal growth (p = 0.041). There was no statistically significant difference between sexes (p = 0.290).

Conclusion

It was concerning that 100% of the hands of HCPs who were about to commence with the surgical list had microbial growth. These HCPs could have already been in contact with patients and equipment in the theatre environment.

Emergence delirium in children undergoing dental surgery under general anesthesia

BACKGROUND

Emergence delirium is a well-described complication in pediatric anesthesia, occurring more often following short surgical procedures using volatile anesthetics with a rapid recovery profile. Dental extractions and conservation dentistry are commonly performed in children and are not painful postoperatively. The use of nerve blocks and local anesthetic infiltration intraoperatively limits nociception and obviates the need for opioids, allowing for more objective assessment of emergence delirium.

AIM

The purpose of this preliminary study was to describe the incidence of emergence delirium and the associated risk factors in children undergoing elective dental surgery under general anesthesia at a regional academic hospital in South Africa.

METHODS

A prospective, descriptive study of healthy children aged 2-6 years was undertaken. Patients were anesthetized using standardized protocols. Assessments included demographics of the child and caregiver, child anxiety at induction using the modified Yale Preoperative Anxiety Scale, intraoperative events, and Paediatric Anaesthesia Emergence Delirium score in the recovery room. Data were assessed for associations and correlations.

RESULTS

Ninety-one children with a mean age of 3.9 (SD = 0.9) years were included. Anxiety was present in 69.2% at induction and emergence delirium occurred in 51.6% of the patients. The mean (SD, range) Paediatric Anaesthesia Emergence Delirium score in the patients without emergence delirium was 7 (2.65, 0-9) and in patients with emergence delirium was 14 (2.52, 10-18). Children with emergence delirium required more interventions in the recovery room but few required pharmacological treatment.

CONCLUSIONS

Emergence delirium occurs commonly after dental surgery, and the majority of the children presenting for dental surgery are anxious at induction. Children with emergence delirium require more interventions in the recovery room but few require pharmacological treatment.

The illuminance of laryngoscopes at two central hospitals

Background: Direct laryngoscopy and successful endotracheal intubation require optimal illumination of laryngeal structures. The International Organization of Standardization (ISO) describes minimum adequate laryngoscope illuminance as 500 lux after 10 minutes, and further describes optimal dimensions of the illumination field. Laryngoscope light is subjectively assessed by the anaesthetist as part of theatre preparation. This study sought to describe the illumination of laryngoscopes at two academic hospitals, to compare illumination of incandescent and fibreoptic laryngoscopes and to compare the accuracy of a mobile phone application (app) to a lux meter. Methods: A prospective, contextual, descriptive study was conducted, testing the illumination of 43 laryngoscopes with a lux meter, as well as a mobile phone app. The illumination field size of each laryngoscope was determined. Results: ISO Standard for illumination was met by 8 (18.6%) laryngoscopes, and 11 (25.5%) had an adequate illumination field. Only 4 (9.3%) laryngoscopes met both criteria. The mobile phone app readings were significantly different from those obtained with a lux meter (p = 0.0008). After battery replacement 23 further laryngoscopes demonstrated an adequate illuminance. No significant difference was found between incandescent and fibreoptic laryngoscope illuminance (p = 0.86). Conclusion: This study demonstrated that the available laryngoscopes had poor illuminance. A mobile phone app was not comparable to a lux meter. Routine objective illuminance testing as well as regular battery changes are suggested to be implemented.

Knowledge of appropriate blood product use in perioperative patients among clinicians at a tertiary hospital

Background: Blood products are an expensive and scarce resource with inherent risks to patients. The current knowledge of rational blood product use among clinicians in South Africa is unknown.Purpose of research: To describe the level of clinicians' knowledge related to all aspects of the ordering and administration of blood products from the South African Blood Services for peri-operative patients at a tertiary hospital.Method: A self-administered survey was distributed to 210 clinicians of different experience levels from the departments of Anaesthesiology, General Surgery and Trauma, Orthopaedic Surgery and Obstetrics and Gynaecology at the study hospital. The questions related to risks, cost, ordering procedures and transfusion triggers for red cell concentrate (RCC), fresh frozen plasma (FFP) and platelets.Results: A total of 172 (81.90%) surveys were returned. The overall mean for correctly answered questions was 16.76 (±4.58). The breakdown by specialty was: Anaesthesiology 19.98 (±3.84), General Surgery and Trauma 16.28 (±4.05), Orthopaedic Surgery 13.83 (±4.17) and Obstetrics and Gynaecology 15.63 (±3.51). Anaesthesiology performed better than other disciplines (p < 0.001) and consultants out-performed their junior colleagues (p < 0.001). Seventy percent correctly identified triggers for RCC transfusion and 50% for platelets. Administration protocols were correctly defined by 80% for RCC and FFP just over 50% for platelets. Thirty eight percent of respondents deemed infectious and non-infectious risk sufficient to obtain informed consent. Knowledge of costs and ordering was below 30%.Conclusion: Clinician's knowledge of risks, resources, costs and ordering of blood products for perioperative patients is poor. Transfusion triggers and administration protocols had an acceptable correct response rate.

National audit of critical care resources in South Africa - nursing profile

OBJECTIVES

(i) To determine the profile and number of nurses working in South African intensive care units (ICUs) and high care units (HCUs); (ii) to determine the number of beds in ICU and HCUs in South Africa; and (iii) to determine the ratio of nurses to ICU/HC beds.

DESIGN AND SETTING

A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and HCUs in South Africa was undertaken.

RESULTS

A 100% was sample obtained; 74.8% of the ICU nursing managers were ICU-trained nurses with an average of 12.8 years of ICU experience. Only 25.6% of nurses working in ICU were ICU trained. The majority were registered nurses (49.2%), while 21.4% were semi-professional nurses. Private sector nurses represented 50.3% of all nurses. Some 42.8% of the professional nurses had 0 - 5 years of experience and 28.7% had 5 - 10 years. The groups 10 - 15 and 15 - 20 years represented 16.1% and 6.6% respectively. Only 5.7% nurses had 20 and more years' experience. In the units that used agency staff the ratio of permanent to agency nursing staff for the month of June 2003 was 64.5% versus 35.5%. In total there are 4,168 ICU and HC beds in South Africa that are serviced by 4,584 professional nurses. The nurse:bed ratio is 1.1 nurses per ICU/HC bed.

CONCLUSIONS

This study demonstrates that ICU nursing in South Africa faces the challenge of an acute shortage of trained and experienced nurses. Our nurses are tired, often not healthy, and are plagued by discontent and low morale.

National audit of critical care resources in South Africa - open versus closed intensive and high care units

OBJECTIVES

To evaluate the distribution and functioning of South African intensive care units (ICUs) and high care units (HCUs), in particular the extent to which units were 'closed units'.

DESIGN AND SETTING

A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken.

RESULTS

A 100% sample was obtained. A total of 396 acute care public and 256 private hospitals were identified; 23% of public hospitals had ICUs and/or HCUs compared with 84% of private hospitals. In the public hospitals there were 210 units and 238 units in the private hospitals. Only 7% of public units and less than 1% of private units were 'ideal closed units'. A total number of 3,414 ICU and high care beds were identified; 71% of beds were in open units versus 29% in closed units. The distribution of ICU and ICU/high care beds comprised 64% in private sector and 36% (1,223) in public units. A total of 244,024 patients were admitted to all units in South Africa during 2002, of whom 63% were to private units and 37% to public sector units.

CONCLUSION

In the face of already limited resources (financial and human) and given the emphasis on primary care medicine (with consequent limited capacity for further ICU development), it is crucial that existing facilities are maximally utilised. Like the USA we are not in a position to implement the Leapfrog recommendations and must modify our approach to dealing with South African realities.

National audit of critical care resources in South Africa - unit and bed distribution

OBJECTIVE

To determine the national distribution of intensive care unit (ICU)/high care (HC) units and beds.

DESIGN AND SETTING

A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICU and high care units in South Africa was undertaken.

RESULTS

A 100% sample was obtained; 23% of public and 84% of private hospitals have ICU/HC units. This translates to 1,783 public and 2,385 private beds. Only 18% of all beds were HC beds. The majority of units and beds (public and private) were located in three provinces: Gauteng, KwaZulu-Natal and the Western Cape. The Eastern Cape and Free State had less than 300 beds per province; the remaining four provinces had 100 or fewer beds per province. The public sector bed: population ratio in the Free State, Gauteng and Western Cape was less than 1:20,000. In the other provinces, the ratio ranged from 1:30,000 to 1:80,000. The majority of units are in level 3 hospitals. The ICU bed: total hospital bed ratio is 1.7% in the public sector compared with 8.9% in the private sector. The ratio is more when the comparison is made only in those hospitals that have ICU beds (3.9% v. 9.6% respectively). In the public and private sector 19.6% beds are dedicated to paediatric and neonatal patients with a similar disparity across all provinces. Most hospitals admit children to mixed medical surgical units. Of all ICU beds across all provinces 2.3% are commissioned but not being utilised.

CONCLUSION

The most compelling conclusion from this study is the need for regionalisation of ICU services in SA.

National audit of critical care resources in South Africa - research methodology

This article provides an in-depth description of the methodology that was followed and the quality control measures that were implemented during the audit of national critical care resources in South Africa.

National audit of critical care resources in South Africa - transfer of critically ill patients

OBJECTIVES

To establish the efficacy of the current system of referral of critical care patients: (i) from public hospitals with no ICU or HCU facilities to hospitals with appropriate facilities; and (ii) from public and private sector hospitals with ICU or HCU facilities to hospitals with appropriate facilities.

DESIGN AND SETTING

A descriptive, non-interventive, observational study design was used. An audit of all public and private sector ICUs and HCUs in South Africa was undertaken.

RESULTS

A 100% sample was obtained; 77% of public and 16% of private hospitals have no IC/HC units. Spread of hospitals was disproportionate across provinces. There was considerable variation (less than 1 hour - 6 hours) in time to collect between provinces and between public hospitals that have or do not have ICU/HCU facilities. In the private hospitals, the mean time to collect was less than an hour. In public hospitals without an ICU, the distance to an ICU was 100 km or less for approximately 50% of hospitals, and less than 10% of these hospitals were more than 300 km away. For hospitals with units (public and private), the distance to an appropriate hospital was 100 km or less for approximately 60% of units while for 10% of hospitals the distance was greater than 300 km. For public hospitals without units the majority of patients were transferred by non-ICU transport. In some instances both public and private hospitals transferred ICU patients from one ICU to another ICU in non-ICU transport.

CONCLUSION

A combination of current resource constraints, the vast distances in some regions of the country and the historical disparities of health resource distribution represent a unique challenge which demands a novel approach to equitable health care appropriation.

Fluid shifts have no influence on ciprofloxacin pharmacokinetics in intensive care patients with intra-abdominal sepsis

This study aimed to investigate whether fluid shifts alter ciprofloxacin pharmacokinetics in critically ill patients over time. Patients > or = 18 years, with normal renal function, requiring intensive care treatment and parenteral antibiotics were enrolled. Group A (22 patients) included patients with documented intra-abdominal infections. Group B (18 patients) included patients with severe sepsis from other causes. All patients received intravenous ciprofloxacin 400 mg every 8 h infused over 60 min. Eight timed blood specimens were taken on days 0, 2 and 7. Ciprofloxacin plasma concentrations were determined using high performance liquid chromatography. There were no significant differences between the pharmacokinetics of the two groups or over time. Ciprofloxacin pharmacokinetics in critically ill patients do not change over time, and intra-abdominal sepsis does not alter ciprofloxacin pharmacokinetic parameters to a greater degree than sepsis from other causes in critically ill patients.

Ciprofloxacin pharmacokinetic profiles in paediatric sepsis: how much ciprofloxacin is enough?

OBJECTIVE

To determine the pharmacokinetic profile of ciprofloxacin 20 mg/kg per day (10 mg/kg administered intravenously 12 hourly) in paediatric patients with severe sepsis.

DESIGN

Open and prospective.

SETTING

Tertiary referral multi-disciplinary ICU.

PATIENTS

Twenty patients (two groups - group A: 3 months-1 year; group B 1-5 years).

INTERVENTIONS

Timed blood samples were taken for pharmacokinetics after the first dose (D(0)), as well as day 2 (D(2)) and then between days 6-8.

MEASUREMENTS AND RESULTS

Ciprofloxacin serum levels were measured by high performance liquid chromatography. Demographic and clinical data and all adverse events were noted. Standard pharmacokinetic variables were calculated by non-compartmental methods. Peak concentrations (C(max)) for group A were D(0) 6.1+/-1.2 mg/l, D(2) 9.0+/-1.8 mg/l and D(7) 5.8+/-1.3 mg/l and, for group B, 7.4+/-1.3 mg/l, 7.8+/-1.6 mg/l and 6.4+/-1.3 mg/l, respectively, for the study periods. Concentration 12 h after the start of infusion (C(min)) for all periods were 0.2 mg/l or less. Areas under the curve (AUC, 12 h) were group A: 15.6+/-1.3, 19.2+/-1.63 and 14.1+/-1.4 mg/h per l, and group B: 15.9+/-1.3, 18.0+/-1.7 and 13.2+/-1.26 mg/h per l. One patient presenting with seizures, initially controlled, had another convulsion and a further patient developed seizures whilst on ciprofloxacin. C(max) in these patients were higher than the average C(max). The convulsions of both patients were easily controlled. No other drug-related serious adverse events occurred. No arthropathy was noted. Three patients died of their underlying disease.

CONCLUSIONS

There was no accumulation of drug even after 7 days of administration. Our C(max) and AUC were lower than that achieved in a similar adult pharmacokinetic study. To achieve end points of area under the inhibitory curve (AUIC) of 100-150 mg/h per l, 10 mg/kg ciprofloxacin eight hourly would be required for some resistant ICU organisms.

Good clinical research practice: what is it and is it possible in the intensive care unit?

With the growing quest for answers to vexing dilemmas in critically ill patients, more intensive care units are embarking on clinical research. This places increasing importance on Good Clinical Research Practice (GCRP), a set of guidelines drawn up by the Pharmaceutical Industry to assist investigators in conducting ethical, reliable scientific studies. GCRP is a combination of good basic management skills allied to ethical principles for scientific research. Based on the principles of the Declaration of Helsinki, it consists of three tenets: patient protection (ethics), credible data (science) and data control. This article describes GCRP specifically relating it to the intensive care situation, illustrating some of the concepts with practical examples. With a minimum of extra time and effort these basic principles can be integrated as routine into all research projects.

Pharmacokinetic profiles of high-dose intravenous ciprofloxacin in severe sepsis. The Baragwanath Ciprofloxacin Study Group

The pharmacokinetics of 400 mg of ciprofloxacin given intravenously (i.v.) every 8 h (q8h) in severely septic adults was documented in a multidisciplinary, tertiary referral intensive care unit (ICU). Sixteen evaluable patients (three pharmacokinetic profiles) without renal dysfunction and with severe sepsis were studied. Ciprofloxacin at a dosage of 400 mg given i.v. q8h was administered over 1 h. Plasma samples for assay (high-pressure liquid chromatography) were taken at timed intervals (preinfusion, at the end of infusion, and at 1, 2, 3, 5, and 7 h postinfusion) for first-dose kinetics (day 0 [D0]), D2, and between D6 and D8. All pharmacokinetic variables were calculated by noncompartmental methods. Standard intensive care was provided. Peak ciprofloxacin concentrations were as follows: D0, 6. 01 +/- 1.93 mg/liter; D2, 6.68 +/- 2.01 mg/liter; and D6 to D8 6.45 +/- 1.54 mg/liter. Trough levels were as follows: D0, 0.6 +/- 0.5 mg/liter; D2, 0.7 +/- 0.4 mg/liter; and D6 to D8 0.6 +/- 0.4 mg/liter. The areas under the concentration curves (8 h) were as follows: D0, 13.3 +/- 3.8 mg . h/liter; D2, 16.8 +/- 5.4 mg . h/liter; and D6 to D8, 15.5 +/- 4.7 mg . h/liter. No drug-related serious adverse events occurred. For 17 of 18 patients enrolled in the study, the causative organisms were susceptible to ciprofloxacin. One patient developed renal failure (non-drug related) after the administration of three doses of ciprofloxacin. One patient was infected with ciprofloxacin-resistant organisms on enrollment. Nine of 16 evaluable patients had clinical cures, and 8 had bacteriological cures. One patient developed a ciprofloxacin-resistant superinfection. In two patients the clinical course was indeterminate. Two bacteriological failures occurred. We conclude that in critically ill adults ciprofloxacin at a dosage of 400 mg given i.v. q8h is safe. Its pharmacokinetic profile provides bactericidal activity against most organisms encountered in an ICU. Except for some initial accumulation on D2, no further accumulation occurred in patients without renal failure. Ciprofloxacin should be administered i.v. at a dosage of 400 mg q8h for severe sepsis.

Critical care research and pre-emptive informed consent: a practical approach used in Chris Hani Baragwanath ICU

OBJECTIVES

1) To establish a protocol within international and local ethical guidelines to obtain informed consent for critical care research, overcoming constraints previously described and 2) To evaluate eventual recruitment using this protocol.

DESIGN

Prospective descriptive study.

SETTING

Multidisciplinary ICU in a community-based university teaching hospital.

PATIENTS AND PARTICIPANTS

Following approval by the University Ethics Committee and Hospital Review Board, patients admitted between January and May 1996 were assessed on weekdays for potential enrollment into existing clinical trials. Discussion with potential candidates and/or next-of-kin occurred at the earliest opportunity and informed consent was obtained preemptively. Next-of-kin was notified if enrollment subsequently occurred. We evaluated the number of patients screened, the number of potential study candidates, the number for whom consent was obtained or refused and the number subsequently enrolled.

INTERVENTIONS

None

RESULTS

Of 249 patients screened, 149 (60%) did not meet the inclusion criteria. Of 100 potential study candidates (40% of all patients screened), we failed to make contact with the next-of-kin in 29 cases (12% of all patients screened). Thus 71 patients or next-of-kin were counselled (28% of all patients screened). In all, 30 patients (12% of all patients screened) were subsequently enrolled into a study.

CONCLUSIONS

A policy of pre-emptive informed consent enabled us to overcome some of the problems previously experienced in our unit with regards to patient enrollment in critical care research. Although overall recruitment remained low, predictions for future enrollment can be made from this study.

Gastric intramucosal pH and blood lactate in severe sepsis

We prospectively investigated the effect of conventional resuscitation on gastric intramucosal pH and lactate over 5 days in a group of patients with newly diagnosed severe sepsis. Lactate and gastric intramucosal pH were measured on entry into the study, as soon as resuscitation end points were met, eight hourly for 48 h and daily for 5 days. Sixteen of 18 patients had a low gastric intramucosal pH (mean (SD) 7.17 (0.12)) at the time of diagnosis of severe sepsis. At no time did gastric intramucosal pH or lactate distinguish between shocked and nonshocked patients. Lactate distinguished survivors from nonsurvivors over time (p = 0.02). Gastric intramucosal pH did not distinguish survivors from nonsurvivors over time (p = 0.72). At 48 h lactate was lower in survivors (p < 0.01) and gastric intramucosal pH higher in survivors (p < 0.05). Receiver operating characteristic curves at this time indicate that lactate is a better predictor of survival. It is likely, based on the inability of gastric intramucosal pH to distinguish survivors from nonsurvivors until 48 h, that it is not possible to use this measurement to guide resuscitation in patients who are severely ill and who have gastric intramucosal acidosis.

Development and validation of a critical care patient classification system

OBJECTIVE: To describe the research methodology used in development and validation of a scientific patient classification instrument for South African critical care patients. METHOD: This is a contextual, exploratory, and descriptive study. A two-phase validating model was used as a research method. In the development phase a literature review was carried out (domain identification), a provisional instrument developed (item generation), and a peer group discussion conducted (item formation). In the quantification phase 16 experts determined if both the items of the instrument and the entire instrument were content valid. The study was conducted within the framework of South African critical care nursing. RESULTS: In the peer group discussion the instrument was debated until consensus was reached. In the quantification phase, both the items of the instrument and the entire instrument were rated as content valid. CONCLUSIONS: Established patient classification systems can be successfully adapted and validated for local use.

Development and validation of a critical care patient classification system

OBJECTIVE

To describe the research methodology used in development and validation of a scientific patient classification instrument for South African critical care patients.

METHOD

This is a contextual, exploratory, and descriptive study. A two-phase validating model was used as a research method. In the development phase a literature review was carried out (domain identification), a provisional instrument developed (item generation), and a peer group discussion conducted (item formation). In the quantification phase 16 experts determined if both the items of the instrument and the entire instrument were content valid. The study was conducted within the framework of South African critical care nursing.

RESULTS

In the peer group discussion the instrument was debated until consensus was reached. In the quantification phase, both the items of the instrument and the entire instrument were rated as content valid.

CONCLUSIONS

Established patient classification systems can be successfully adapted and validated for local use.

A guideline for competency of the critical care nurse

BACKGROUND: To maintain a high standard of quality nursing care the individual critical care nurse s competencies should be determined objectively. Few international guidelines describe the qualities required by critical care nurses to function effectively in a critical care unit. These guidelines often focus only on the education and training of critical care nurses. OBJECTIVE: To formulate and describe guidelines for the competency requirements of registered critical care nurses. METHOD: A focus group interview, a qualitative research method, was conducted as an open conversation in which each participant could ask questions, comment, or respond to comments. Interaction among the respondents was encouraged to stimulate in-depth discussion. The study was conducted within the framework of South African critical care nursing. RESULTS: The four main categories that were identified are as follows: professional competence, cognitive competence, interpersonal skills, and critical care patterns of interaction. These are described in detail along with a formulated guideline for critical care nurse competency requirements. CONCLUSION: This study describes an attempt to formulate objective guidelines for critical care nurses competency requirements.

A guideline for competency of the critical care nurse

BACKGROUND

To maintain a high standard of quality nursing care the individual critical care nurse s competencies should be determined objectively. Few international guidelines describe the qualities required by critical care nurses to function effectively in a critical care unit. These guidelines often focus only on the education and training of critical care nurses.

OBJECTIVE

To formulate and describe guidelines for the competency requirements of registered critical care nurses.

METHOD

A focus group interview, a qualitative research method, was conducted as an open conversation in which each participant could ask questions, comment, or respond to comments. Interaction among the respondents was encouraged to stimulate in-depth discussion. The study was conducted within the framework of South African critical care nursing.

RESULTS

The four main categories that were identified are as follows: professional competence, cognitive competence, interpersonal skills, and critical care patterns of interaction. These are described in detail along with a formulated guideline for critical care nurse competency requirements.

CONCLUSION

This study describes an attempt to formulate objective guidelines for critical care nurses competency requirements.

Accuracy of pulse oximetry in pigmented patients

OBJECTIVE

Prospective assessment of the accuracy of three pulse oximeters and two probe sites in darkly pigmented critically ill patients under clinical conditions.

PATIENTS AND METHODS

One hundred consecutive, darkly pigmented critically ill adult patients with arterial lines in situ were studied. Patients were excluded if the haemoglobin concentration was less than 7 g/dl and carboxyhaemoglobin or methaemoglobin levels exceeded 2%. Pigmentation was objectively quantified with a portable EEL reflectance spectrophotometer (Evans Electroselenium Company, Diffusion Systems Limited, London). Reflectance was measured at nine wavelengths.

RESULTS

The degree of pigmentation as measured by percentage reflectance closely matched that of a control group of black Africans from a pigmentation study. The limits of agreement (2.6% to 5.8%), precision and bias values between pulse oximeter and co-oximeter readings fell within a narrow range. The 95% confidence intervals of the limits of agreement reflected a small variation in the difference between pulse oximeter and co-oximeter readings. These small differences were not clinically significant in the pigmented patients who were enrolled in the study.

CONCLUSION

The accuracy of pulse oximetry is not adversely affected by skin pigmentation, and it remains a useful oxygenation monitoring device in darkly pigmented patients.

Changes in vancomycin pharmacokinetics in critically ill infants

We aimed to assess the pharmacokinetics of vancomycin in critically ill infants, and to evaluate the standard recommended dose of 10 mg/kg 6 hourly. All infants admitted to the Baragwanath Hospital ICU who had arterial lines in situ, and for whom vancomycin 10 mg/kg 6 hourly was prescribed for an infective insult and who had parental consent, were included in the study. Vancomycin was infused over 60 minutes. Serum samples were taken immediately before the dose and at 30, 60, 120 and 300 minutes after the end of the vancomycin infusion, on days 2 and 8 of therapy. Extrapolated peak concentration (Cmax), trough concentration (Cmin), apparent volume of distribution (Vd), elimination half-life (t1/2el) and clearance (CL) were determined for each patient. Day 2 values were compared with those of day 8. Day 2 serum concentrations were assayed on 20 patients and day 8 concentrations in 15. The mean vancomycin Vd on day 2 (0.81 l/kg) was significantly (P = 0.007) larger than that on day 8 (0.44 l/kg). The change in Vd resulted in a significant change in mean Cmax (29.1 vs 35.5 micrograms/ml) (P = 0.02) and mean t1/2el (5.3 vs 3.4h) (P = 0.01) over the treatment period. Critically ill infants displayed a large initial volume of distribution which probably resulted from aggressive fluid resuscitation. This also results in a large variation in other pharmacokinetic parameters, namely Cmax and t1/2el. Although the routine monitoring of vancomycin serum concentrations remain controversial, we feel that in view of these large pharmacokinetic variations, the critically ill infant is a specific group where monitoring of vancomycin serum levels is indicated.

Acute lung injury at Baragwanath ICU. An eight-month audit and call for consensus for other organ failure in the adult respiratory distress syndrome

To test the expanded definition of acute lung injury (ALI), we prospectively, over a period of 8 months, studied all adult ICU admissions who fitted the definition. Our study consisted of 83 patients with the adult respiratory distress syndrome (ARDS) and 60 with mild to moderate ALI. Sepsis and trauma were the most common diagnoses on admission. The overall mortality rate was 45 percent for ARDS and 38 percent in the other group. Mortality rose significantly with associated other organ failure, the incidence of which was as follows: hepatic, 39 percent; cardiac, 38 percent; hematologic, 22 percent; renal, 21 percent; neurologic, 5 percent. Sepsis syndrome eventually occurred in 73 percent and septic shock in 38 percent of all cases of ALI. We found the expanded definition a useful grading system and consider this definition of ARDS to be currently the best. There are, however, problems with the determination of lung compliance, the effect of inverse ratio ventilation, and the lack of consensus in defining other organ failure.

High-dose adrenaline in adult in-hospital asystolic cardiopulmonary resuscitation: a double-blind randomised trial

Forty intensive care unit patients requiring cardiopulmonary resuscitation were randomised to receive either the standard dose of adrenaline (1 mg every five minutes) or high-dose adrenaline (10 mg every five minutes). In the majority of patients, overwhelming sepsis was the major contributing factor leading to cardiac arrest. In this group of patients no difference could be detected in response to high-dose adrenaline compared with the standard dose. Although no side-effects were noted with this high dose of adrenaline, more investigation is required prior to its routine use in cardiopulmonary resuscitation.