Preventable mortality in geriatric hip fracture inpatients.

There is a high rate of mortality in elderly patients who sustain a fracture of the hip. We aimed to determine the rate of preventable mortality and errors during the management of these patients. A 12 month prospective study was performed on patients aged > 65 years who had sustained a fracture of the hip. This was conducted at a Level 1 Trauma Centre with no orthogeriatric service. A multidisciplinary review of the medical records by four specialists was performed to analyse errors of management and elements of preventable mortality. During 2011, there were 437 patients aged > 65 years admitted with a fracture of the hip (85 years (66 to 99)) and 20 died while in hospital (86.3 years (67 to 96)). A total of 152 errors were identified in the 80 individual reviews of the 20 deaths. A total of 99 errors (65%) were thought to have at least a moderate effect on death; 45 reviews considering death (57%) were thought to have potentially been preventable. Agreement between the panel of reviewers on the preventability of death was fair. A larger-scale assessment of preventable mortality in elderly patients who sustain a fracture of the hip is required. Multidisciplinary review panels could be considered as part of the quality assurance process in the management of these patients.

Efficacy of continuous venovenous hemodialysis in the treatment of severe lithium toxicity.

The syndrome of lithium toxicity has been well described. Hemodialysis is the recommended treatment for severe toxicity. We report a case in which continuous venovenous hemodialysis was used in the treatment of lithium toxicity. The calculated average lithium clearance was 23 mL per minute, comparing favorably with that of normal renal clearance (20-30 mL/min) and of intermittent hemodialysis (50-100 mL/min). This report discusses the potential benefits of this therapy in a hemodynamically unstable patient who may not tolerate hemodialysis.

The third five-year survey of fellows (by examination) of the Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists.

A questionnaire was sent to 126 Fellows who had passed the Fellowship Examination in Intensive Care up to and including the examination of October, 1995. The major objectives were to assess the continuing involvement of Fellows in Intensive Care and obtain feedback on training and the examinations. Only six Fellows failed to respond. Ninety-six per cent of responders had some involvement in Intensive Care and 89% had a current formal Intensive Care appointment. The median percentage of the week spent in the Intensive Care was high. Forty-seven per cent were practising some anaesthesia. Although there was considerable individual variation, the Fellows had not changed their median amount of Intensive Care practice over time. The responders provided feedback on their work patterns in the public and private systems, and their training and examinations. Overall, the training/examination system appears to satisfy Fellows although some fine tuning is required.

A survey of Fellows of the Faculty of Anaesthetists of the Royal Australasian College of Surgeons endorsed in intensive care by examination in the first 10 years of final examinations in intensive care.

Fifty-nine of the 70 Fellows of the Faculty of Anaesthetists who had passed the Final Examination in Intensive Care including that of October 1989, responded to a questionnaire on the pattern of their intensive care and anaesthetic practice and their perception of the training and examination. Responses came predominantly from Fellows who had passed the examination more than two years previously. Forty-eight (81%) were practising intensive care at least 50% of the time and 51% had become Director or Deputy Director of an Intensive Care Unit. However, 51% maintained some anaesthetic practice. Although individuals had changed the intensive care/anaesthetic distribution of their practice, the group overall had not. With one exception all Fellows were practising in public hospitals but 26% in private hospitals also. Only eight had sought intensive care as their first vocational qualification. Training and examination were generally regarded favourably except for training in research methods and experience in internal medicine. The results suggest that the intensive care specialist is not likely to leave such practice in the long term, but there has been a reluctance to abandon altogether training and some subsequent practice in anaesthetics.

Peri-operative care for oesophagectomy patients.

The aim of this study was to evaluate factors relevant to morbidity and mortality in 54 patients undergoing oesophagectomy at Royal Newcastle Hospital between 1985 and March 1989. There was a high incidence of concurrent medical problems. Significant anaesthetic complications occurred in 6 patients. There were 16 serious general medical complications and 10 surgical complications. Respiratory complications included basal collapse (19), sputum retention (6), pulmonary oedema (2), pleural effusion/haemothorax (5), and severe aspiration syndrome (5). Seven patients required mechanical ventilation for more than 3 days. Two deaths occurred postoperatively. As a result of this audit, changes have occurred in patient selection, management of chylothorax, epidural analgesia and timing of tracheal extubation.

Altered aminoglycoside pharmacokinetics in the critically ill.

We studied prospectively 49 patients being treated in an intensive care unit with aminoglycosides for gram-negative sepsis. Pharmacokinetic data were calculated from three post-dose serum levels using a one-compartment model. Doses required to achieve peak levels between 5 and 10 mg/l with trough levels approximately 1.0 mg/l ranged between 2 and 12 mg/kg per day (mean dose 7 mg/kg per day). During therapy 60% of the patients had a change in their apparent volume of distribution (Vd) of greater than 20%. These patients were likely to have confirmed infection and to be febrile at the start of treatment. Two to three weeks after discharge ten patients were restudied after a single dose of aminoglycoside. There was a reduction in mean Vd from 0.24 to 0.18 l/kg (P less than 0.02). Critically ill patients have significantly larger volumes of distribution and may require larger doses per kilogram of body weight of aminoglycoside to achieve therapeutic concentrations. Due to considerable variation in kinetic parameters, the use of standard doses or dosing nomograms is not recommended.

A survey of successful FFARACS candidates in Australasia.

As of October 1985, 37 candidates have passed the final examination in intensive care for the Diploma of Fellow of the Faculty of Anaesthetists, Royal Australasian College of Surgeons (FFARACS). In September 1984, 23 of these successful candidates responded to a questionnaire seeking information on their educational experiences during training and the nature of their work since the examination. At that time, six were staff specialists in anesthetic practice, one was involved in full-time intensive care research, one was the director of an accident and emergency center, and the remaining 15 were full-time staff specialists or senior registrars in intensive care. The responses to the questions on training indicated that more intensive care and medical experience were considered desirable. Most felt that their training and the examination were useful in determining long-term employment, satisfactory performance in intensive care, and personal job satisfaction.

Factors affecting outcome after chest injury.

From 1978 to 1983 a total of 328 patients was admitted to Royal Newcastle Hospital Intensive Care Unit with chest injuries; 255 had other injuries as well. Of the 328, 171 developed acute respiratory failure, 174 received mechanical ventilation (159 for acute respiratory failure) and 46 died. The commonest causes of death were head injury (19), sepsis (10) and uncontrollable haemorrhage (10). Associated head (131) and/or abdominal (89) injuries tripled mortality. Those without respiratory, cardiac, renal or hepatic failure (155) had a mortality rate of 5.8% while the remainder had mortality rates of 21.6%, 12.5%, 37.5% and 100%, for respiratory (171), cardiac (8), renal (8) and hepatic (5) failures, respectively. Shock was present on admission in 55, of whom 19 died. Sepsis developed in 59 and 14 with this complication died. Sepsis remains a potentially avoidable late cause of death and attention needs to be directed towards limiting invasive techniques of management to those which are necessary, and towards early diagnosis of abdominal injuries with early exploratory surgery. The best chance of survival in the initial phase of injury may lie in the establishment of an integrated regional trauma centre system together with improved pre-hospital and retrieval systems.

Lingual haematoma leading to upper airway obstruction.

A case is reported in which upper airway obstruction occurred in a patient following suturing of his lacerated tongue under local anaesthesia and the subsequent development of a large lingual haematoma.

Evaluation of the technique of central venous catheterisation via the external jugular vein using the J-wire.

This paper reports the results of a prospective study to evaluate the success rate and incidence of complications with the external jugular approach to central venous cannulation using a J-tipped spring guide wire. In a personal series of 100 consecutive patients in whom the technique was attempted, successful placement was achieved in 90, but more importantly there were no immediate technical complications. During the study, internal jugular cannulation was used in fourteen patients because either an external jugular vein was not visible (four patients), could not be cannulated (three patients), or the guide wire could not be manipulated into an intrathoracic position (seven patients). The technique is recommended as the initial method where central venous cannulation must be performed under suboptimal conditions and in very sick patients in whom a serious complication may prove to be fatal.