Multiple intra-hospital transports during relocation to a new critical care unit.

OBJECTIVE: Intra-hospital transport (IHT) of critically ill patients is associated with morbidity and mortality. Mass transfer of patients, as happens with unit relocation, is poorly described. We outline the process and adverse events associated with the relocation of a critical care unit. DESIGN: Extensive planning of the relocation targeted patient and equipment transfer, reduction in clinical pressure prior to the event and patient care during the relocation phase. SETTING: The setting was a 30-bed, tertiary referral, combined medical and surgical critical care unit, located in a 570-bed hospital that serves as the national referral centre for cardiothoracic surgery and spinal injuries. PARTICIPANTS: All stakeholders relevant to the critical care unit relocation were involved, including nursing and medical staff, porters, information technology services, laboratory staff, project development managers, pharmacy staff and building contractors. MAIN OUTCOME MEASURES: Mortality at discharge from critical care unit and discharge from hospital were the main outcome measures. A wide range of adverse events were prospectively recorded, as were transfer times. RESULTS: Twenty-one patients underwent IHT, with a median transfer time of 10 min. Two transfers were complicated by equipment failure and three patients experienced an episode of hypotension requiring intervention. There were no cases of central venous or arterial catheter or endotracheal tube dislodgement, and hospital mortality at 30 days was 14%. CONCLUSION: Although IHT is associated with morbidity and mortality, careful logistical planning allows for efficient transfer with low complication rates.

Evaluation of the effect of intra-operative intravenous fluid on post-operative pain and pulmonary function: a randomized trial comparing 10 and 30 ml kg(-1) of crystalloid.

BACKGROUND: Existing evidence suggests that administration of intravenous fluids has been shown to improve outcomes including pain in gynecological laparoscopic surgery but the optimum fluid dose has not been determined. AIMS: To determine the effect of administration of intravenous fluids on post-operative pain and pulmonary function after gynecological laparoscopy. METHODS: In a prospective randomized double-blinded study 100 ASA 1 and 2 elective patients undergoing gynecological laparoscopy were randomized to receive intravenous compound sodium lactate 10 ml kg(-1) (CSL10-restrictive) or 30 ml kg(-1) (CSL30-liberal) administered intra-operatively. The primary outcome measure was the post-operative pain score at 24, 48 and 72 h, assessed by 0-10 verbal rating scale (VRS). Pulmonary function (FEV1, FVC, PEFR) and oxygen saturation were also measured. RESULTS: Patients who received CSL 30 had lower post-operative pain scores than CSL 10 (ANCOVA-mean difference = 0.47, 95 % CI 0.11-0.83, P = 0.01). Post-operative pain VRS was lower in CSL30 than CSL10 at 48 h (mean difference 0.56, 95 % CI 0.04-1.09, P = 0.036). Patients in CSL30 reported shoulder tip pain less frequently than those in CSL10 (30.4 vs. 43.9 % of assessments, P = 0.03, OR 0.58) but reported wound pain more frequently 39.0 vs. 24.2 %, P = 0.01, OR 2.0). Indices of pulmonary function did not differ between groups at any time. CONCLUSIONS: Liberal compared to restrictive administration of i.v. crystalloid is associated with a clinical modest reduction in pain. Pulmonary dysfunction was not increased with liberal fluid administration.

Catheter-related infection in Irish intensive care units diagnosed with HELICS criteria: a multi-centre surveillance study.

BACKGROUND: Catheter-related infection (CRI) surveillance is advocated as a healthcare quality indicator. However, there is no national CRI surveillance programme or standardized CRI definitions in Irish intensive care units (ICUs). AIM: To examine the feasibility of multi-centre CRI surveillance in nine Irish ICUs, using Hospitals in Europe Link for Infection Control through Surveillance (HELICS) definitions (CRI 1, CRI 2 and CRI 3). METHODS: All non-tunnelled central venous catheters (CVCs) inserted in patients aged >18 years with an ICU stay ≥48 h were included over a three-month study period. FINDINGS: Feasibility was demonstrated by the 99.5% return rate for study forms. Data on 1209 CVCs in 614 patients over 7587 CVC-days showed 17 episodes of CRI, representing a national rate of 2.2 per 1000 CVC-days [95% confidence interval (CI) 1.2-3.3]. Rates of CRI 1, CRI 2 and CRI 3 were 0.13 (95% CI 0.00-0.39), 0.79 (95% CI 0.16-1.42) and 1.39 (95% CI 0.60-2.17) per 1000 CVC-days, respectively. CRI was associated with length of ICU stay (P < 0.001), number of CVCs inserted (P < 0.001) and total number of CVC-days per patient (P < 0.001). CRI was higher in CVCs inserted in operating theatres (incident rate ratio 3.9, 95% CI 1.3-11.5; P = 0.02) compared with CVCs inserted in ICUs. Participant feedback reported minimal difficulty with surveillance implementation, and data collection required approximately 1 h per patient per week. CONCLUSION: The study demonstrated that multi-centre ICU surveillance using HELICS CRI definitions was practical, feasible and provided clinically relevant information. CRI surveillance in ICUs, although labour intensive, is recommended to reduce CRI and allow ongoing evaluation of processes aimed at CRI reduction.

Antimicrobial usage in an intensive care unit: a prospective analysis.

Antimicrobial therapies in the Intensive Care Unit (ICU) need to be appropriate in both their antimicrobial cover and duration. We performed a prospective observational study of admissions to our semi-closed ICU over a three-month period and recorded the indications for antimicrobial therapy, agents used, duration of use, changes in therapy and reasons for changes in therapy. A change in therapy was defined as the initiation or discontinuation of an antimicrobial agent. There were 51 patients admitted during the three-month study period and all received antimicrobial therapy. There were 135 changes in antimicrobial therapy. 89 (66%) were made by the ICU team and 32 (24%) were made by the primary team. Changes were made due to a deterioration or lack of clinical response in 41 (30%) cases, due to the completion of prescribed course in 36 (27%) cases, and in response to a sensitivity result in 25 (19%) cases. Prophylactic antibiotic courses (n=24) were of a duration greater than 24 hours in 15 (63%) instances. In conclusion, the majority of changes in antimicrobial therapy were not culture-based and the duration of surgical prophylaxis was in excess of current recommended guidelines.

Comparison of transversus abdominis plane block vs spinal morphine for pain relief after Caesarean section.

BACKGROUND: Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial. METHODS: Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 µg (S(M)) or saline (S(S)) and a postoperative bilateral TAP block with either bupivacaine (T(LA)) 2 mg kg(-1) or saline (T(S)). RESULTS: Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S(M)T(LA) (20 mm)

The functional outcome and recovery of patients admitted to an intensive care unit following drug overdose: a follow-up study.

Patients who have overdosed on drugs commonly present to emergency departments, with only the most severe cases requiring intensive care unit (ICU) admission. Such patients typically survive hospitalisation. We studied their longer term functional outcomes and recovery patterns which have not been well described. All patients admitted to the 18-bed ICU of a university-affiliated teaching hospital following drug overdoses between 1 January 2004 and 31 December 2006 were identified. With ethical approval, we evaluated the functional outcome and recovery patterns of the surviving patients 31 months after presentation, by telephone or personal interview. These were recorded as Glasgow outcome score, Karnofsky performance index and present work status. During the three years studied, 43 patients were identified as being admitted to our ICU because of an overdose. The average age was 34 years, 72% were male and the mean APACHE II score was 16.7. Of these, 32 were discharged from hospital alive. Follow-up data was attained on all of them. At a median of 31 months follow-up, a further eight had died. Of the 24 surviving there were 13 unemployed, seven employed and four in custody. The median Glasgow outcome score of survivors was 4.5, their Karnofsky score 80. Admission to ICU for treatment of overdose is associated with a very high risk of death in both the short- and long-term. While excellent functional recovery is achievable, 16% of survivors were held in custody and 54% unemployed.