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.
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.
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.
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.
Vitamin D deficiency and outcome of patients with sepsis in pediatric intensive care unit: a prospective observational study
Abstract
Background: Vitamin D is important in immunomodulation, regulation of inflammation and cytokines, cell proliferation, cell differentiation, apoptosis, angiogenesis, muscle strength, and muscle contraction. Patients with sepsis have high mortality rate and high deficiency in vitamin D. (1) Vitamin D is increasingly recognized as an important mediator of immune function and may have a preventive role in the pathogenesis of sepsis. (2) Vitamin D also influence cardiovascular function. (3) We aimed to find the correlation of vitamin D level with severity of sepsis in patients admitted to pediatric intensive care unit (PICU).
Setting: Participants and laboratory were collected from patients with sepsis who admitted to the PICU at Dr. Sardjito General Hospital, Yogyakarta.
Patients and Participants: Participants pediatric sepsis patients admitted to the PICU from September 2015 to April 2016. Blood samples for 25-hydroxyvitamin D [25(OH)D] concentration were collected at the first 24 hours admission in PICU using ELISA method. Other data recorded include pediatric logistic organ dysfunction (PELOD) score at admission, PICU length of stay and mortality.
Measurement and results: A total of 297 patients were admitted to the PICU during the 8-month study period. Fourty-two patients had diagnosis of sepsis, severe sepsis or septic shock on PICU admission. Of all these studied patients, 25(OH)D deficiency was identified in 23 (54.8%) patients, insufficiency in 9 (21.4%) patients, and normal levels in 10 (23.8%) patients. PICU mortality was higher in patients with 25(OH)D deficiency, ie 7 (30.44%) patients, but it did not show any statistical significance compared to the group of patients with 25(OH)D insufficiency or normal level of 25(OH)D group of patients (p=0.78). The group with normal level of 25(OH)D had the highest PELOD score but on the other hand they have the lowest mortality rate.
Conclusions: There is a high prevalence of vitamin D deficiency in pediatric sepsis patients admitted to PICU, but not correlated with PELOD score on admission. PICU lenght of stay also not associated with mortality in PICU.
Electrocardiography Holter monitoring abnormalities in acute intracerebral hemorrhages
Abstract
Objective: To avoid the misinterpretation of electrocardiogram (ECG) abnormalities in acute intracerebral hemorrhage (ICH), it is important to recognize ECG abnormalities in such patients. Previous studies have reported ECG disorders in ICH patients based on a single ECG tracing. In this study, we used ECG Holter monitoring to determine ECG abnormalities in acute ICH patients.
Methods: This was a prospective analysis of acute (up to 24 hours following admission) non-traumatic ICH patients who were admitted to our hospital between January 2014 and April 2015. Initially, an ECG and cerebral computed tomography (CT) scan were obtained within the first day of admission. The patients then underwent ECG Holter monitoring for 24 hours. Finally, the ECG abnormalities and their association with the CT scan findings were analyzed.
Results: This study included 108 patients with acute non-traumatic ICH. The most frequent ECG abnormalities shown by Holter monitoring were ectopic beats (85.2%), followed by sinus tachycardia (63.2%). Only the presence of midline shift on the CT scan had a significant correlation with ectopic beats (OR: 1.3, CI: 1.05-1.7).
Conclusion: ECG Holter monitoring in 108 acute ICH patients demonstrated a correlation between the presence of midline shift on the cranial CT scan and ectopic beats in the ECG Holter monitoring.
Initial caloric administration as a risk factor for mortality in critically ill children
Abstract
Background: The mortality rate of critically ill children with multiple organ dysfunction syndrome (MODS) in Indonesia is approximately 51.85%. Various studies suggested malnutrition as a risk factor for mortality; therefore, nutrition therapy in the form of initial caloric administration became imperative.
Objective: To determine the relationship between initial caloric administration (initial route, initial time and the fulfilment of caloric requirement) and mortality of critically ill children.
Design: Case-control study.
Setting: The Pediatric Intensive Care Unit (PICU) of Dr. Sardjito General Hospital Yogyakarta in 2015.
Patients and participants: Children aged 1 month to 18 years old hospitalized in the PICU for at least 4 days in 2015. Subjects were divided into case group (non-surviving patients) and control group (surviving patients).
Measurements and results: We used McNemar test and stepwise conditional logistic regression for data analysis. From 102 subjects (51 in each group), the proportion of malnourished children in the case group was higher than in the control group (58.8% and 29.4%, respectively). Parenteral route and lack of caloric achievement within the 3rd to 6th day of hospitalization significantly increased the risk of mortality (p<0.05) with ORs of 13 (95%CI 1.95 to 552.47), 3.8 (95%CI 1.37 to 13.02), 4.25 (95%CI 1.39 to 17.26), 4.00 (95%CI 1.08 to 22.09), and 10.0 (95%CI 1.42 to 433.98), respectively. Caloric initiation after the first 48 hours of hospitalization did not significantly affect the mortality rate (p>0.05). Confounding variables that affected mortality include the severity of disease, use of ventilator, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and malnutrition (p<0.05). Multivariate analysis revealed that parenteral route and malnutrition significantly influenced mortality with ORs of 36.05 (95%CI 3.22 to 404.13) and 9.04 (95%CI 2.09 to 39.19), respectively.
Conclusion: There is a relationship between route of initial caloric administration and mortality of critically ill children, where parenteral nutrition significantly influenced mortality in critically ill children.
Characteristics of the obstetric patients admitted to the Intensive Care Unit of Sanglah General Hospital in 2013-2016
Abstract
Background: High risk pregnancy and complication during pregnancy or labor may need multidisciplinary management in the Intensive Care Unit (ICU). This study shows the characteristics of obstetric patients who were admitted to the ICU of Sanglah General Hospital Denpasar, Bali, Indonesia in 2013 to 2016.
Objective: Our study was performed to provide database in Sanglah General Hospital regarding to the intensive care management of obstetric patients in the ICU of Sanglah General Hospital. This data may be beneficial to provide better management in the ICU, and also to reduce maternal mortality and morbidity.
Design: This was a descriptive study using the secondary data from the medical records of obstetric patients who were admitted to the ICU of Sanglah General Hospital in 2013 to 2016.
Setting: This study was performed in the ICU of Sanglah General Hospital, Denpasar, Bali, Indonesia.
Patients and participants: All obstetric patients who were admitted or transferred to ICU of Sanglah General Hospital in August 1, 2013 to August 31, 2016. There were 245 obstetric patients transferred to ICU of Sanglah General Hospital.
Result: Over the 3 years study period, there were 245 obstetric patients who were admitted to the ICU out of the total of 3089 deliveries during that period. Based on the gestational age during admission, there were 7.7% cases below 28 weeks (n=19), 36.3% were between 28-36 weeks gestational age (n=89), and 55.9% cases were 37 weeks and above (n=137). The indication of the admission can be categorized into the obstetrics indication, which were 75.1% out of 245 cases (n=184) and the non-obstetric indication such as the medical problem underlying during the pregnancy, which were about 24.9% out of 245 cases (n=61). The major indication of obstetric problem was the hypertensive disease in pregnancy, while the major indication of nonobstetric reason was the heart disease. The maternal mortality rate in the ICU during this study was 10.2% out of the 245 cases who were admitted to the ICU.
Conclusion: As the major tertiary referral hospital in Bali, Sanglah General Hospital were having high number of complicated pregnancy cases. The characteristics of the obstetric patients who were admitted to the ICU can be used to plan better management and appropriate care, especially in the ICU, in order to reduce the maternal mortality rate.
Prevalence and association of cost and hospital malnutrition in Pediatric Intensive Care Unit Sanglah Hospital during 2015
Abstract
Background: Early nutritional screening and adequate enteral nutrition for critically ill patients, started 24 hours after admission in pediatric intensive care unit (PICU) are accepted to improve health outcomes. Malnutrition prior to admission worsens the prognosis of severely ill children and it will lead to a higher mortality, a longer length of stay, and a higher health cost.
Objective: The main outcome was to investigate the prevalence of hospital malnutrition on admission, discharge, and in-hospital in PICU Sanglah Hospital, Bali during 2015. The secondary outcome was to investigate the association of cost and hospital malnutrition.
Methods: A retrospective study was conducted in PICU Sanglah Hospital, Bali, from January to December 2015.
Patients and participants: Children aged 1 month to 12 years with complete medical records. We assessed the prevalence of hospital malnutrition using WHO Anthro software or WHO AnthroPlus software.
Results: From January to December 2015, there were 477 patients admitted to the PICU and 456 were enrolled in this study. Malnutrition was observed in 72 patients (15.8%) during PICU admission, 56 (17.2%) during discharged, and only 13 (2.9%) suffered from malnutrition during hospitalization. Multivariate analysis showed that malignancy was the only factor associated with in-hospital malnutrition. Malnutrition during admission and discharge were not associated with an increase in the length of hospital stay. But, in-hospital malnutrition was associated with longer length of stay (3.2 vs 14.0 days, p<0.001), and was associated with additional cost of Rp 5,500,000.
Conclusion: Malnutrition was observed in 72 patients during PICU admission, 56 during discharged and only 13 during hospitalization. Hospital malnutrition was associated with additional cost of Rp 5,500,000.