An eight year audit before and after the introduction of modified early warning score (MEWS) charts, of patients admitted to a tertiary referral intensive care unit after CPR.

AIMS: To determine whether cardiac arrest calls, the proportion of adult patients admitted to intensive care after CPR and their associated mortalities were reduced, in a four year period after the introduction of a 24/7 Critical Care Outreach Service and MEWS (Modified Early Warning System) Charts. METHODS: A retrospective analysis of prospectively collected data during two four-year periods, (2002-05 and 2006-09) in a UK University Teaching Hospital Comparisons were via χ(2) test. A p value of ≤0.05 was regarded as being significant. RESULTS: In the second audit period, compared to the first one, the number of cardiac arrest calls relative to adult hospital admissions decreased significantly (0.2% vs. 0.4%; p<0.0001), the proportion of patients admitted to intensive care having undergone in-hospital CPR fell significantly (2% vs. 3%; p=0.004) as did the in-hospital mortality of these patients (42% vs. 52%; p=0.05). CONCLUSION: The four years following the introduction of a 24/7 Critical Care Outreach Service and MEWS Charts were associated with significant reductions in the incidence of cardiac arrest calls, the proportion of patients admitted to intensive care having undergone in-hospital CPR and their in-hospital mortality.

Decreasing delays in urgent and expedited surgery in a university teaching hospital through audit and communication between peri-operative and surgical directorates.

National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of 'after-midnight' operating to immediate life-, limb- or organ-threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre-operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability.

Early noncardiogenic pulmonary edema and the use of PEEP and prone ventilation after emergency liver transplantation.

Noncardiogenic pulmonary edema in liver transplant recipients is usually secondary to TRALI (transfusion related acute lung injury) or liver ischemic-reperfusion injury. If persistent, the resultant hypoxemia is associated with increased ventilator days, prolonged length of stay (intensive care and hospital) and increased 28-day mortality. Ventilation strategies for the management of hypoxemia in acute lung injury include moderate to high levels of PEEP (positive and expiratory pressure) and prone ventilation (PV). Such strategies have theoretical adverse effects on graft perfusion. Evidence does however exist to demonstrate that maintenance of cardiac output and correct positioning of the prone patient to allow abdominal excursion can negate the deleterious effects of PEEP and PV. A liver transplant recipient became profoundly hypoxemic on our intensive care unit following the onset of noncardiogenic pulmonary edema. A risk-benefit assessment performed at the time deemed that the potential adverse effects of PEEP and PV were outweighed by the life-threatening nature of hypoxemia. The patient's condition improved following prone positioning and application of PEEP (10-15 cm H(2)O). We conclude that such ventilation strategies are appropriate in hypoxemic liver transplant recipients if an appropriate risk-benefit assessment is performed.

The use of drotrecogin alfa (activated) in a patient with recent orthotopic liver transplant.

Drotrecogin alfa has been shown to reduce mortality in severe sepsis. However, it remains unlicensed for use in patients with previous liver transplantation. We report its use in such a case. Prior to administration a risk benefit analysis was performed in line with General Medical Council recommendations. This included being satisfied that no appropriately licensed alternative would better serve the patient's needs and that sufficient evidence existed to demonstrate the safety and efficacy of the drug. Responsibility was taken for prescription, monitoring and follow up. The process was carefully documented and the patient recovered fully with no adverse effects. To date the only published data on the use of drotrecogin alpha in transplant recipients is a case series of three patients. Further published data may encourage review of the licence.

Thomas the Tank Engine and Friends improve the understanding of oxygen delivery and the pathophysiology of hypoxaemia.

Understanding basic pathophysiological principles underpins the practice of many healthcare workers, particularly in a critical care setting. Undergraduate curricula have the potential to separate physiology teaching from clinical contexts, making understanding difficult. We therefore assessed the use of analogous imagery as an aid to understanding. Two groups of first year physiotherapy students were randomly assigned to receive either a control lecture (oxygen delivery and hypoxaemia) or a study lecture (control lecture plus images of a train set delivering rocks: an analogy to oxygen delivery.) Qualitative assessment of the lectures showed a significant (p < 0.001) improvement in understanding by the study group, and increased the proportion of students that found the lecture 'interesting and stimulating' (p = 0.01). Quantitative assessment demonstrated a significant increase in the multiple choice questionnaire marks of the study group (p = 0.03). In conclusion, analogous imagery can significantly increase the understanding of this physiological concept.

Deliberate self poisonings in children and adolescents--a frightening scourge.

Paediatricians may be called on to see a suicidal child or adolescent in the emergency department as a psychiatric consultation is not always immediately available. The paediatrician will then play a pivotal role in the evaluation and disposition of the patient.(1) American reports have shown that 8% of high school students have made a suicidal attempt and that 2% had made an attempt that required medical attention.(2) Suicidal attempts account for 12% of all emergency department visits for the adolescent age group.(3) In the U.K. overdoses account for 4.7% of all general hospital admission in those aged 12-20 years. (4) In Republic of Ireland the most recent national vital statistics data revealed that over a period of one year July'97 - July '98, more than 650 children and adolescents were admitted to hospital with the deliberate self poisoning. The female to male ratio was 3:1.(7)

Outcome of acute intussusception in a regional paediatric centre.

It has been suggested recently that acute intussusception should only be managed in a specialised paediatric centre. The aim of this study is to assess the incidence and outcome of acute intussusception in a comprehensive paediatric unit in Waterford Regional Hospital. It is a retrospective medical records study over a ten year period from June 1990 to June 2000. Our results showed that we had 24 cases giving an incidence of 2.4 cases per year. Contrast enema was performed in 23(95%) cases, successfully reduced in 14(61%) cases, unsuccessfully reduced in 7(30%). Surgical intervention was necessary in 7(30%) cases. Three (12.5%) cases were transferred to a specialised paediatric surgical centre. There were no perforation or death. We conclude from this study that management of acute intussusception can be successfully undertaken in a regional paediatric centre. It requires adequate throughput of cases and close co-operation between paediatrician, radiologist, anaesthetist, surgeons and of course a dedicated paediatric nursing staff.

Prophylaxis in RSV infection (Palivizumab)--is it worthwhile?

Respiratory syncytial virus (RSV) is a recognised cause of lower respiratory tract infection in infants and young children. It causes severe respiratory disease in preterm infants with or without chronic lung disease. This study, conducted at Waterford Regional Hospital, evaluates the incidence of RSV infection in hospitalised children, its seasonal variation, and effectiveness of its prevention. Thirty eight percent of admitted children with bronchiolitis were RSV positive in the year 1999 November to March is the peak season for this infection. A highly selected group of 7 preterm children with or without chronic lung disease received Palivizumab prophylaxis. Not one of them acquired RSV infection. The high cost of Palivizumab was the main factor for its restricted use. Palivizumab was found to be effective in preventing RSV infection in our study. Since we had a small number of patients, further studies are needed for its economic and judicious use. Respiratory syncytial virus (RSV) is virulent easily transmissible and the most common cause of lower respiratory tract disease in children of less than 2 years of age. Up to 98% of children attending day care will be infected in single RSV season. Between 0.5% and 3.2% of children with RSV infection require Hospitalisation. Approximately 90,000 hospital admissions and 4500 deaths per year were reported in United States. In Ireland 2807 patients were admitted with Bronchiolitis in 1998. Major risk factors for hospitalisation due to RSV are Prematurity, chronic lung disease, congenital heart disease, compromised immunity and age younger then 6 weeks in otherwise healthy children. No effective treatment of RSV positive bronchiolitis beside supportive care in the form of adequate nutrition and oxygen therapy is available. Antiviral therapies such as Ribavirin has not been proved to be effective in RSV infection. Bronchodilators show variable results. Corticosteroids were not found effective. There is no effective vaccine available as yet. There is no proven method for active immunity. Various immunoglobulins are available for acquiring passive immunity against RSV infection. PREVENT study group in Jan. 1997 showed intravenous immunoglobulin (RSV- IGIV) use in reducing 41% to 63% hospitalisation in RSV patients. But RSV-IGIV was not licensed outside the United States because of risk of transmission of blood borne products, difficulty in administration ie. intravenous access, large fluid volume (15 ml/kg), high protein load (750 mg/kg), shortage of supply and need to postpone live vaccine (eg. MMR, varicella). monoclonal antibody Palivizumab was developed for prophylaxis against RSV infection. Clinical safety and efficacy of Palivizumab were demonstrated in IMpact trial published in Sept. 1998. Reduction in hospitalisation up to 55% was noted in this study. It was a pivotal randomised, double blind, placebo controlled phase 3 study conducted in 139 centres throughout Canada, United States and United Kingdom. We looked at our experience in patients admitted with bronchiolitis in Waterford Regional Hospital. We described the outcome of carefully selected Seven children of high risk group for Palivizumab prophylaxis. Its clinical Implications and cost effectiveness was evaluated in this study.

Inadequate assessment of the airway and ventilation in acute poisoning. A need for improved education?

AIMS AND OBJECTIVES: To analyse the initial management of acute poisoning patients, and whether respiratory morbidity was related to inadequate assessment of airway and ventilation. METHODS: A retrospective analysis of the assessment and resuscitation of a group of acute poisoning patients, as documented in the clinical records. SUBJECTS AND SETTING: Forty one patients admitted to either Intensive Care or Coronary Care Units in a UK teaching hospital with a diagnosis of acute poisoning, between 12 January 1997 and 21 January 1998. STANDARDS: Advanced Life Support Guidelines were used to compare initial assessment. Criteria for intubation and ventilation described by Gentleman was used as the standard for intubation. RESULTS: Thirty seven patients had documented Glasgow Coma Scales at the time of admission, 27 were managed appropriately; one exhibited signs of aspiration. Ten patients were judged to be managed inappropriately; six exhibited clinical signs of aspiration. Four patients had unidentified Glasgow Coma Scales. CONCLUSIONS: Increased emphasis on 'Airway and Breathing' remains necessary in medical education. Regional recommendations for the management of acute poisoning require 'intubation guidelines'. Appropriate ward settings for monitoring such patients may pre-empt the onset of major respiratory problems.