Delirium in critically ill patients: incidence, risk factors and outcomes
Abstract
Objective: To determine the incidence, and evaluate the risk factors and outcomes of delirium in general Intensive Care Unit (ICU).
Design: Prospective cross-sectional observational study.
Setting: Teaching hospital in Kuala Lumpur, Malaysia.
Patients and participants: Patients ages of 18 and above admitted for more than 24 hours in general ICU were recruited into the study.
Measurements and results:The demographic data, predisposing and precipitating factors, and environmental factors were collected. Confusional Assessment Method (CAM-ICU) was done daily to assess delirium, when the patient had a sedation score of above Richmond Agitation and Sedation Scale (RASS) -3. Patients were followed up till discharged from ICU. Length of mechanical ventilation and length of ICU stay were recorded.
A total of 139 patients were recruited with overall incidence of delirium was 42%. Among patients who had delirium, 68% were of hypoactive delirium, 25% of mixed delirium and 7% were hyperactive delirium. The significant predisposing risk factors for developing delirium were age, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, visual or hearing impairment, smoking, renal impairment, diabetes, and hypertension. The factors detected precipitating delirium were sepsis, use of vasopressors, renal replacement therapies, and acute respiratory distress syndrome (ARDS). The presence of catheters, higher Sequential Organ Failure Assessment (SOFA) scores, and abnormal urea and bilirubin levels further significantly increased risk of delirium. Environmental conditions increasing the risk of delirium included absence of daylight exposure and visible clocks, and use of physical restraints. As a result of delirium, patients had longer length of mechanical ventilation and ICU stay.Conclusions: Recognizing predisposing factors and optimizing the modifiable risk factors will improve the length of mechanical ventilation and ICU stay.
Dispatcher-assisted cardiopulmonary resuscitation improves the neurological outcomes of out-of-hospital cardiac arrest victims: a retrospective analysis of prehospitalisation records in Kumamoto City
Abstract
Background: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is an effective tool for improving the outcome of out-of-hospital cardiac arrest (OHCA) by providing dispatcher assistance (DA) to bystander cardiopulmonary resuscitation (BCPR) and public access defibrillators (PAD). However, it is unclear whether DA-CPR improves the neurological outcomes of OHCA. In this study, we assessed the effectiveness of DA-CPR using prehospitalisation records in Kumamoto City (Japan), which has a population of 730,000, an area of 390 km2, and 25 ambulances. The DA-CPR protocol in Kumamoto City commenced in 2014.
Methods: We retrospectively analysed the prehospitalisation records in Kumamoto City between 2014 and 2016. The cases were divided into two groups according to whether they received DA: DA group and non-DA group. The BCPR and PAD rates were compared between the two groups. The neurological outcomes (Glasgow–Pittsburgh cerebral performance category 1–2) were compared between the two groups by propensity score analysis with inverse probability of treatment weighting.
Results: A total of 1607 prehospitalisation records were identified and divided into the DA (n=1132) and non-DA (n=474) groups. BCPR (72% vs 17%, p<0.001) and PAD (11% vs 5%, p<0.001) rates were greater in the DA group. Propensity score analysis showed that the neurological outcome was significantly better in the DA group (odds ratio 1.718; 95% confidence interval: 1.017-2.902; p=0.0431).Conclusions: DA-CPR was associated with improved BCPR, PAD, and neurological outcomes of OHCA in this analysis of prehospitalisation cases in Kumamoto City.
The successful treatment of severe aspiration pneumonitis with the combination of hydrocortisone, ascorbic acid and thiamine
Abstract
Aspiration pneumonitis is a neutrophil mediated inflammatory pneumonitis following the aspiration of regurgitated gastric contents. This syndrome occurs most commonly in patients with depressed levels of consciousness such as drug overdose, seizures, and during anesthesia. Aspiration pneumonitis is the most common cause of anesthesia-related deaths. Aspiration pneumonitis may be clinically silent or present as severe acute lung injury (ARDS) progressing to death. The treatment of acid aspiration pneumonitis is largely supportive. We present two cases of severe life threatening ARDS due to acid aspiration who were treated with the combination of hydrocortisone, ascorbic acid, and thiamine (HAT) and made a dramatic recovery. This treatment strategy should be considered in the management of patients with aspiration pneumonitis.
The accuracy of SIRS criteria, qSOFA and SOFA for mortality suspected sepsis patient admitted to the Intensive Care Unit Dr. Hasan Sadikin General Hospital Bandung, January-December 2017
Abstract
Objective: The high mortality rate found on infectious patients in the intensive care unit (ICU) calls for sepsis identification tools. Sepsis consensus introduced Systemic Inflammatory Response Syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Sequential Organ Failure Assessment (SOFA) score. This study aimed at comparing the accuracy and quality to discriminate among the SIRS, qSOFA score, and SOFA score for predicting mortality among patients at risk of sepsis admitted to the ICU.
Design: This study used the analytic observational method with retrospective cohort approach to a sample of 73 qualified medical record data. The data regarding the SIRS, qSOFA, and SOFA criteria were applied after 24 hours of ICU admission.
Setting: ICU of Dr. Hasan Sadikin General Hospital, Bandung from January to December 2017.
Measurements and results: The results of this study showed the SOFA score as being the most accurate and having a good quality to discriminate, with the value of area under the receiver operating characteristic (AUROC) 0.866 (95% CI 0.782-0.95; p=0.00); the qSOFA score had AUROC of 0.707 (95% CI 0.588-0.826; p=0.002) while SIRS criteria were not significant.Conclusions: The conclusion of this study is that in patients with suspected sepsis admitted to an ICU, the SOFA score is the most accurate to predict mortality, whereas qSOFA could be considered and the SIRS criteria is not recommended.
Prediction of optimal right internal jugular vein catheter depth: comparison between Peres’ formula and intracavitary ECG
Abstract
Background: Incorrect central venous catheter (CVC) placement can lead to serious complications. In order to prevent complications, CVC insertion depth can be predicted using Peres’ formula or intracavitary electrocardiography (ECG). The accurate prediction of optimal CVC depth using Peres’ formula and intracavitary ECG on Malay race is unknown.
Objective: To compare the accuracy of Peres’ formula and intracavitary ECG in predicting the optimal depth of right internal jugular venous catheter on adult Malay race.
Methods: This was a comparative analytic observational study with cross sectional design conducted at Cipto Mangunkusumo National General Hospital Jakarta from May to July 2017. After obtaining approval from the local ethical committee, right internal jugular venous catheter insertion was attempted on 111 patients, but 7 subjects were excluded from the study. Statistical analysis was performed on 104 samples to determine the accuracy of CVC depth prediction based on Peres’ formula and intracavitary ECG using McNemar’s test. The CVC depth prediction formula in adult Malay subject was calculated using linear regression based on its correlation with age, height, and body weight.
Results: The accuracy of intracavitary ECG and Peres’ formula to predict the optimal depth of right internal jugular venous catheter was 75% and 11.5%, respectively. The difference between the accuracy of these two methods was statistically significant (p=0.001). Correlation analysis showed a significant relationship between height and the optimal depth of right internal jugular vein catheter. The CVC depth prediction formula obtained in this study was 4.143 + (0.058 x height in cm).Conclusion: Prediction of right internal jugular venous catheter depth using intracavitary ECG is more accurate than the Peres’ formula.
Secondary pyomyositis complicated by septic shock and sepsis-induced cardiomyopathy causing a massive erector spinae abscess in a patient after trigger point injection
Abstract
Trigger point injection is a common pain control method widely practiced around the world.
We report the case of a 53-year-old female who presented with lumbago and septic shock complicated with sepsis-induced cardiomyopathy three days after receiving a trigger point injection. She responded to sepsis treatment and empiric antibiotics but later required extensive drainage and debridement after a follow-up CT scan revealed a massive abscess above the fascia of erector spinae spanning from the level of the 1st thoracic spine to the 5th lumbar spine. With extensive surgical drainage and effective antimicrobial treatment, the patient recovered fully and was discharged without any sequelae.
Post-surgical right coronary artery injury secondary to tricuspid valve repair
Abstract
Injury to the right coronary artery (RCA) is a rare complication of tricuspid annuloplasty. We report a 64-year-old woman with history of valvular heart disease that was admitted for decompensated right heart failure. The patient underwent aortic valve replacement and tricuspid annuloplasty. Shortly after tricuspid annuloplasty the patient developed right ventricular (RV) infarction with hemodynamic compromise. The coronary angiogram shows subtotal occlusion at the mid segment of right coronary artery probably due to stitch of the tricuspid ring. The RCA has successfully been revascularized by percutaneous coronary angioplasty with bare metal stent, however the patient got into multi-organs failure syndrome and died at day 15 postoperatively.
Intubation practices at Wellington Hospital Emergency Department: an eight month retrospective observational study
Abstract
Objective: To determine the rate of intubations carried out in Wellington Hospital Emergency Department (tertiary hospital), New Zealand, to provide a description of intubating habits of clinicians including operator experience and methods, and to determine the rate of complications.
Design: Eight month, retrospective, observational study.
Setting: Wellington Hospital Emergency Department(WHED).
Location: New Zealand.
Patients and participants: All patients intubated in the Emergency Department were included.
Interventions: None. Audit related activity.
Measurements and results: Over the eight months 57 intubations occurred. The most common indications for intubation were head injury with reduced Glasgow Coma Scale (GCS) and overdose (both 18.9%) followed by stroke, seizure and cardiac arrest (9.4-11.3%). Most intubations (46%) occurred between 8 a.m.-5 p.m. Eighty-two point seven percent of patients were intubated by ED doctors where seniority of team leader and intubating doctor varied according to the time of day. Intubation was consultant led 68.4% of the time before 5 p.m. and 40% of the time overnight. Airway checklist use was reported in 54.5% with formal airway assessment documented in 50%. Successful first pass occurred in 77.2% of cases. Difficult laryngoscopy (grade 3-4) was reported in 16.6% using direct laryngoscopy and 18.8% using videolaryngoscopy. All patients were successfully intubated orally in 3 attempts or less. Etomidate was drug of choice (54.7%). Seventeen point five percent experienced one or more complications. Trends towards less complications related to direct laryngoscopy compared to videolaryngoscopy and use of cricoid pressure associated with a higher complication rate were noted. However there were low numbers and statistical significance was not reached.
Conclusion: The first pass success rate for intubation was lower in comparison to other studies although adverse event rate was also lower. As a high-risk procedure, an incidence of seven intubations per month highlights the need for more diverse training opportunities for skills maintenance.
Late pacemaker perforation of the right ventricle. A case report and review of diagnosis and management
Abstract
Objectives: Pacemaker incidence and prevalence are on the rise over the last decade especially in the elderly population. Though complications are rare, most reported literature is about early pacemaker complication. Late complications are also reported, but mostly regarding malfunction or infections. Very few case reports and series report late cardiac perforations which could be catastrophic. We report a case of late cardiac perforation diagnosed and treated in our institution to raise the awareness of this very serious complication.
Case summary: A 65-year-old male who had a single chamber right ventricular pacemaker inserted two months earlier for sick sinus syndrome, presented to the hospital with complaint of shortness of breath. Chest X-ray (CXR) revealed new large left sided pleural effusions. Computed tomography (CT) scan of the chest suggested migration of the pacemaker lead with perforation of the right ventricle associated with hemothorax with no pericardial effusions. A bedside echo confirmed the perforation and showed minimal pericardial effusions with no cardiac tamponade. Clinically patient was hemodynamically stable. He underwent open surgical repair and placement of epicardial pacer leads.
Conclusions: Clinicians should be aware of the early and late complications of pacemaker insertions and how to diagnose and treat them appropriately to avoid unnecessary morbidity or mortality.
Anticholinergic drug-induced benign unilateral anisocoria: common, but frequently overlooked side effect
Abstract
Sudden anisocoria have always been ominous signs among critically ill patients, which requires prompt attention. There are various causes of anisocoria, which call for comprehensive evaluation to rule out neurologic causes such as Adie’s pupil, uncal herniation, compression of third cranial nerve, meningeal irritation, and seizures as opposed to the pharmacological causes such as anticholinergic drugs, anesthesia, and recreational drugs versus causes such as migraine and trauma to the eye. We hereby report a case of a patient with unilateral anisocoria from dilated left pupil due to the nebulized ipratropium bromide, a cholinergic antagonist that resolved with discontinuation of the medication. The purpose of this case report is to emphasize the importance of thorough physical assessment, an early review of the medications, and the use of inexpensive diagnostic test to save time and avoid the expensive diagnostic study.
The optimal ICU organizational structure
A variety of intensive care units (ICU) staffing models exist, which to a large extent are based on local practice and economic factors rather than cost-effectiveness and the quality of care delivered. The organizational structure of ICU in the United States are usually classified according to two types of models, namely a low- or high intensity model, or an open- or closed ICU model. (1,2) In a low-intensity ICU, patients are managed by non-intensivists, however an intensivist may be consulted on some cases (open model), whereas in a high-intensity model intensivists are consulted on all patients (open model) or the intensivist assumes responsibility for the patient and directs all aspects of the care (closed model). The closed ICU structure is the predominant model in almost all Western nations. (3,4) There are significant organizational differences between open and closed ICU. Open units are those in which admission of patients to the ICU is uncontrolled and management of the patients is at the discretion of each attending physician (not an intensivist). Admissions are based on a first-come, first-served basis. As the attending of record does not have the time nor skills to provide “comprehensive critical care” he/she "portions off" the patients' care to a number of organ specific sub-specialists.
Toward having safe environment in critical care units: a multisite study
Abstract
Objective: This study was conducted to assess the safety culture in Jordanian intensive care units.
Design: The study was descriptive, cross-sectional design, and multisite.
Setting: The Safety Attitude Questionnaire-Intensive Care Unit (SAQ-ICU) version was utilized. Three hundred completed questionnaires were returned from four critical care units.
Results: The results offered a fundamental element for further research on safety matter in Jordanian ICUs. Many recommendations were highlighted by the Jordanian nurses in order to improve the safety culture in the ICUs including standard nurse-patients ratio, good communication and collaboration between health professionals, enhance continuing education and training. To the knowledge, this is the first study conducted in Jordan using the SAQ to examine nurses’ safety culture attitudes in Jordanian ICUs.
Conclusion: The present findings provide a baseline for future research aiming for improving the quality of care in Jordanian ICUs.
Respiratory arrest following CT guided selective cervical nerve root injection
CT guided cervical nerve root injection is performed for diagnostic purposes or to reduce inflammation and pain in cervical radiculopathy. Steroid and local anaesthetic are injected under CT guidance around the nerve root. This is performed as an outpatient procedure with most patients being able to be discharged 15-30 mins after the procedure. CT guidance allows the operator to see the best pathway for the needle whilst visualising structures such as the carotid and vertebral artery.
It is generally a safe procedure, with one recent study by RS Pobiel et al showing out of 802 fluoroscopy guided cervical nerve root blockades there were no major complications.
Resuscitation after cardiac surgery in Australia: a survey of practice and the implementation of a training course
Abstract
Objective: To characterise the out-of-hours cover of Cardiac-Surgical Intensive Care Units in Australia, the experience of covering physicians in the training, and management of, cardiac arrest after cardiac surgery, and to describe a novel educational course.
Design: Nighttime phone survey with doctors on public cardiac intensive care units across Australia. Members of nursing, intensive care, and cardiac surgery staff, devised a dedicated half-day course to address the principles of managing a cardiac arrest post-cardiac surgery.
Setting: Tertiary teaching hospital in Sydney, New South Wales, Australia.
Patients and Participants: No patient data used. Qualitative and quantitative feedback from doctors covering intensive care units, and participants, on a pilot course designed to formally train medical and nursing personnel in the management of cardiac arrest after cardiac surgery.
Interventions: Design and implementation of a new training course.
Measurements and Results: We demonstrated wide variation in the availability of training opportunities in Cardiac-surgical Unit-Advanced Life Support, with few units having cardiothoracic surgical doctors on site at night, and the majority of units being covered by a registrar grade, intensive care trainee, out-of-hours. Our pilot course was feasible, well received, and demonstrated improvements in candidates’ confidence in managing cardiac arrests, and their ability to perform, or assist with, emergency re-sternotomy.
Conclusions: The experience of doctors covering cardiac intensive care units varies greatly. There is a lack of dedicated guidelines covering the management of cardiac arrest in the post-cardiac surgical population, with wide variability in whether institutions offer training for this emergency, and how frequently these opportunities are available. There is also a lack of trained medical staff on-site, out-of-hours, able to perform emergency re-sternotomy.
Colistin resistance in organisms causing ventilator-associated pneumonia - Are we going into pre-antibiotic era?
Abstract
Introduction: Ventilator-associated pneumonia (VAP) is one of the most common infections in mechanically ventilated patients. VAP is usually caused by multidrug resistant bacteria. The beta-lactam antibiotics, which were once considered the backbone of antibiotic therapy is under strain due to a variety of bacterial antibiotic resistance. Recent evidence suggests that colistin is the only cannon left in the medical armory to treat bacterial infections, mainly those acquired in the hospital that no other drug can treat. But excessive use of colistin has recently led to resistance to these group of drugs. Initially, resistance to colistin was due to mutations but recently detected plasmid-mediated colistin resistance, which is transferrable, heralds the breach of the last group of antibiotics, polymixins. Colistin resistance is on the rise, especially in South East Asia countries. So strict infection control policies are required to control the spread of this infection.
Objective: This study was conducted to see the burden of colistin resistant organisms causing VAP in ICU of Himalayan Institute of Medical Sciences, Dehradun, India.
Design: A prospective observational study.
Setting: Study was conducted in a 40-bed semi-closed ICU of a tertiary care super specialized hospital between August 2016 to April 2017.
Patients and participants: Out of 2304 patients admitted to ICU 420 had a suspicion of VAP. A total of 476 lower respiratory tract samples were collected from 400 patients with clinical evidence of lower respiratory tract infections in form of endotracheal (ET) aspirate, tracheal tube (TT) aspirate, and bronchoalveolar lavage (BAL) specimens.
Intervention: Organism identification and the susceptibility testing were done by using an automated system VITEK 2.
Result: Out of 476 sample received, only 186 samples organisms were isolated, which showed Acinetobacter baumanii was the most common organism. It was found that 19 organisms had resistance to colistin. Klebsiella pneumoniae (25.7%) was the most common organism, which was resistant to colistin, followed by Pseudomonas aeruginosa (16%) and Acinetobacter baumanii (2.4%).
Conclusion: The emergence of colistin resistant strains is a very serious problem as there are only few treatment options. As colistin use is a risk factor for colistin resistance, colistin should not be used alone, combination therapy should be preferred.