Mediastinal emphysema simulating acute pericarditis.

A case of extensive subcutaneous emphysema, retropneumoperitoneum and mediastinal emphysema is described. The mediastinal emphysema was associated with signs and symptoms of pericardial tamponade, and previously undocumented ECG changes, consistent with acute pericarditis, were noted.

Intra-abdominal pressure measurement using a modified nasogastric tube: description and validation of a new technique.

OBJECTIVE: This study assessed the accuracy of an intragastric method of measuring intra-abdominal pressure (IAP). DESIGN: Prospective sequential study with simultaneous paired measurement of gastric and urinary bladder pressures. SETTING: Operating theatre, University Teaching Hospital. PATIENTS: 9 patients undergoing laparoscopic cholecystectomy were studied. INTERVENTIONS: Intraperitoneal pressures were monitored during peritoneal insufflation at laparoscopy up to a pressure of 20 mmHg. MEASUREMENTS AND RESULTS: Intra-abdominal pressure measurements were recorded simultaneously using a gastric balloon and urinary catheter. Gastric pressure may be up to 4 mmHg higher or 3 mmHg lower than urinary bladder pressure. CONCLUSIONS: Intra-abdominal pressure can be measured easily in this new fashion, allowing a continuous pressure trend to be obtained without interfering with urinary output estimation.

Problems following discharge after intensive care.

Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Do nurses know when to summon emergency assistance?

At Liverpool Hospital in 1989, mortality from cardiopulmonary arrest was 71% in the general wards, and 64% in the Emergency department. In an attempt to identify and treat seriously ill patients before they progressed to cardiac arrest, a medical emergency team (MET) was established. The MET replaced the existing cardiac arrest team and comprised a nurse from the intensive care unit (ICU), a resuscitation registrar (an anaesthetics trainee), a medical registrar and a senior registrar from the ICU. The resuscitation registrar was the team leader. The calling criteria for the MET were based on predetermined physiological variables, abnormal laboratory results, and specific conditions or if nursing or medical staff were concerned by the patient's condition. A study was conducted 2 years following implementation of the MET system, to determine registered nurses' (RNs) opinions, knowledge and use of the system. A questionnaire distributed to 141 nurses rostered on the chosen study date revealed a positive attitude the MET, although there was a low awareness regarding the availability of the MET information booklet. 53% of nurses had called the MET in the last 3 months; all would call the team again in the same circumstances. The correct response in three of four hypothetical situations presented was to call the MET. The number of correct responses varied between scenarios from 17-73%. Hypotension did not appear to alert nurses to summon emergency assistance. Some nurses, despite the presence of severe deterioration and patient distress, called the resident rather than the MET.(ABSTRACT TRUNCATED AT 250 WORDS)

Fluid balance charts: do they measure up?

Many current nursing activities are performed without regular reviews of their usefulness. The recording of fluid gains and losses on a fluid balance chart is one such activity. This article explores the practice of fluid monitoring on the wards of a university teaching hospital.

Pneumoretroperitoneum.

Pneumoretroperitoneum is rare, but sometimes seen in association with pneumoperitoneum as a result of barotrauma to the lungs. However, there have only been two previous cases of pneumoretroperitoneum without pneumoperitoneum following barotrauma. This case discusses several of the possible mechanisms by which this could occur and what associated signs, especially on chest X-ray, one should look for to confirm the aetiology of gas in the retroperitoneal space.

Asynchronous independent lung ventilation (AILV).

A new technique is described for selective lung ventilation of patients with predominantly unilateral pulmonary pathology. Separate ventilators were used to inflate each lung via a double lumen endobronchial tube and no attempt was made to synchronize them. In three of the four cases, there was considerable improvement in respiratory function and radiographic appearance. In no case was there any cardiovascular depression. The use of a new endobronchial tube, the "broncho-cath", suitable for this technique is also described.

The end of the crystalloid era? A new approach to peri-operative fluid administration.

The metabolic response to surgery causes sodium and water retention. It does not seem logical to pour crystalloid solutions into patients in the peri-operative period, particularly when these solutions can cause deterioration in lung function. Plasma volume must be maintained to prevent a decreased blood flow to vital organs such as the kidneys. Blood or colloid solutions, not crystalloid solutions, should be used for this purpose, since the latter are distributed throughout the whole extracellular space and are less effective in maintaining plasma volume. Water given as 5% dextrose should be given in minimal quantities to maintain intracellular hydration. Patients undergoing minor to moderate surgery when they are likely to be drinking within 24 hours do not usually require any intravenous infusion. Moreover, to administer intravenous fluids to these patients may cause harm. No fluid regimens should be inflexible and the patient's size, age and fluid losses should be taken into account.

Active management of the dying patient.

OBJECTIVE: To document the process of managing the dying patient in the intensive care unit (ICU) and thus to broaden community debate about an issue that is usually only discussed at a theoretical or philosophical level. SETTING: A six-bed ICU in Liverpool Hospital, a 419-bed teaching institution in the southwestern area of Sydney. PATIENTS: Twenty-seven patients, seen over a nine-month period, who had curative treatment withdrawn or withheld. The mean age of the patients was 68 years and the severity of illness, by the APACHE II scoring system, ranged from 12 to 45. INTERVENTIONS: Twenty-three of the 27 patients were mechanically ventilated and 11 were receiving inotropic support. Medical staff usually initiated discussions and sought staff consensus that the patient should be allowed to die (on 23 of 27 occasions). Most relatives (25 of 27) accepted this decision. Support therapies and routine care were stopped according to policy guidelines. Sedatives and narcotics were used in some patients (18 of 27). Twenty-one patients died in the ICU and six in the general ward areas. CONCLUSION: Introduction of a policy to guide management of dying patients in intensive care has been accepted by staff. Most dying patients are now managed in accordance with these guidelines. Further discussion and debate of this important issue, by health professionals and society as a whole, is required.

The use of "quality-adjusted life years" (QALYs) to evaluate treatment in intensive care.

This study examines the feasibility of using Quality-Adjusted Life Years (QALYs) to assess patient outcome and the economic justification of treatment in an Intensive Care Unit (ICU). 248 patients were followed for three years after admission. Survival and quality of life for each patient was evaluated. Outcome for each patient was quantified in discounted Quality-Adjusted Life Years (dQALYs). The economic justification of treatment was evaluated by comparing the total and marginal cost per dQALY for this patient group with the published cost per QALY for other medical interventions. 150 patients were alive after three years. Quality of life for most longterm survivors was good. Patient outcome (QALYs) was greatest for asthma and trauma patients, and least for cardiogenic pulmonary oedema. The tentative estimated cost-effectiveness of treatment varied from AUD $297 per QALY for asthma to AUD $2323 per QALY for patients with pulmonary oedema. This compares favourably with many preventative and non-acute medical treatments. Although the methodology is developmental, the measurement of patient outcome using QALYs appears to be feasible in a general hospital ICU.

The Medical Emergency Team.

The concept of a Medical Emergency Team was developed in order to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions. The aim of this study was to describe the utilization and outcome of Medical Emergency Team interventions over a one-year period at a teaching hospital in South Western Sydney. Data was collected prospectively using a standardized form. Cardiopulmonary resuscitation occurred in 148/522 (28%) calls. Alerting the team using the specific condition criteria occurred in 253/522 (48%) calls and on physiological/pathological abnormality criteria in 121/522 (23%) calls. Survival rate to hospital discharge following cardiopulmonary arrest was low (29%), compared with other medical emergencies (76%).

Study of diarrhea in critically ill patients.

There has been an impression that diarrhea occurs commonly in seriously ill patients treated in ICUs. In view of the sparsity of published work on the problem, we embarked on a prospective study of all patients admitted to the ICU for more than 48 h over a 12-month period. Three factors were examined in detail: nasogastric feeding, cimetidine administration, and antibiotic treatment. Other factors also were considered, notably the nature of the underlying illness and the spread of a possible infective agent by cross-infection. There was a 41% incidence of diarrhea. A significant increase in the incidence of diarrhea occurred in patients on nasogastric feeding (p less than 0.01) and in those receiving cimetidine (p less than 0.05); there was no increased incidence in those receiving antibiotic therapy. The cytotoxin of Clostridium difficile was specifically looked for in all patients with diarrhea, but was not detected.

Automatic ventilation with the Ayre's T-piece. A modification of the Nuffield Series 200 ventilator for neonatal and paediatric use.

A simple modification to an existing adult ventilator has been designed to permit mechanical ventilation of neonates and small children with the Ayre's T-piece circuit. The Nuffield Anaesthesia Ventilator Series 200 has been modified by replacing the piston in the patient valve with a fixed leak. This arrangement avoids the problems of critical adjustment commonly encountered with other methods of converting adult ventilators to paediatric use, and allows the ventilator controls to be used normally. The ventilator has been assessed according to the proposed International Standards Organization specifications for the evaluation of the performance of lung ventilators, and the results are described in detail. The modified ventilator is shown to perform as a time-cycled pressure generator capable of delivering tidal volumes between 10 and 300 ml at frequencies from 10 to 85/minute. It is therefore ideally suited to neonatal and paediatric use.

Tests of six continuous flow CPAP devices.

Six continuous flow CPAP devices were tested for pressure fluctuation and stability of inhaled oxygen concentration under conditions of simulated respiration. Four of the systems, the Ambu, Auspap, Downs'-Vital Signs and the Dräger are commercially available and two, the Prince Henry (PHH) and the Prince of Wales (POW) systems were assembled from Bird respirator parts, which were available in the respective Intensive Care Units. All appeared to be clinically effective. The Ambu offers convenience and economy of gases, the Dräger showed the least pressure fluctuations. Three of the four commercial systems lacked certain safety features which could more easily be added to the two non-commercial devices.