Characteristics of patients requiring prolonged length of stay in a surgical intensive care unit in Barbados.

OBJECTIVE: To evaluate the clinical characteristics and costs incurred for patients who stayed for a prolonged period in a surgical intensive care unit (ICU). DESIGN AND METHODS: Data of all patients admitted to a surgical ICU in Barbados during the period of two years from July 1999 to June 2001 were prospectively collected. Demographic data, diagnoses on admission and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. Costs for treatment were calculated from using a cost block model. The characteristics of patients who had a prolonged stay (> 14 days) were compared with a concurrent cohort of patients who stayed less than 14 days. RESULTS: Of 438 admissions, 58 (13.2%) stayed in the ICU for more than two weeks. The overall age, hospital outcome, APACHE II scores in the prolonged stay group were significantly higher than that of the patients who stayed less than two weeks. Cost analysis showed about six times more expenditure in the long stay patients (dollar US 3800 vs dollar US 24000). Of the prolonged stay ICU patients, 29.2% would have required only a step-down unit due to less severity of illness as evidenced by their low mean APACHE II scores [7.3 +/- 2.6 (SD)] compared to overall mean APACHE II score 10.7 +/- 7.5 (SD). CONCLUSION: The study highlighted the need for a step-down unit and a protocol to transfer eligible patients to such a unit.

Characteristics of patients requiring prolonged length of stay in a surgical intensive care unit in Barbados / Características de los pacientes que requieren una prolongada estancia en una unidad quirúrgica de cuidados intensivos en Barbados

OBJECTIVE: To evaluate the clinical characteristics and costs incurred for patients who stayed for a prolonged period in a surgical intensive care unit (ICU). DESIGN AND METHODS: Data of all patients admitted to a surgical ICU in Barbados during the period of two years from July 1999 to June 2001 were prospectively collected. Demographic data, diagnoses on admission and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. Costs for treatment were calculated from using a cost block model. The characteristics of patients who had a prolonged stay (> 14 days) were compared with a concurrent cohort of patients who stayed less than 14 days. RESULTS: Of 438 admissions, 58 (13.2) stayed in the ICU for more than two weeks. The overall age, hospital outcome, APACHE II scores in the prolonged stay group were significantly higher than that of the patients who stayed less than two weeks. Cost analysis showed about six times more expenditure in the long stay patients (dollar US 3800 vs dollar US 24000). Of the prolonged stay ICU patients, 29.2would have required only a step-down unit due to less severity of illness as evidenced by their low mean APACHE II scores [7.3 +/- 2.6 (SD)] compared to overall mean APACHE II score 10.7 +/- 7.5 (SD). CONCLUSION: The study highlighted the need for a step-down unit and a protocol to transfer eligible patients to such a unit.

OBJETIVO: Evaluar las características clínicas y costos en que incurren los pacientes que permanecen un periodo prolongado de tiempo en una unidad quirúrgica de cuidados intensivos (UCI). DISEÑO Y MÉTODOS: Los datos de todos los pacientes ingresados en una UCI en Barbados durante el período de dos años de julio de 1999 a junio de 2001 de junio, fueron recopilados de manera prospectiva. Se registraron los datos demográficos, los diagnósticos al momento del ingreso, y la puntuación APACHE II. Se calcularon los costos del tratamiento mediante un modelo de bloques del costo. Las características de los pacientes que tuvieron una estancia prolongada (> 14 días) fueron comparadas con una cohorte concurrente de pacientes que permanecieron menos de 14 días. RESULTADOS: De 438 admisiones, 58 (13.2%) permaneció en la UCI por más de dos semanas. La edad general, el resultado hospitalario y la puntuación APACHE II fueron significativamente más altos en el grupo de estancia prolongada que en el de los pacientes que permanecieron menos de dos semanas. El análisis del costo mostró aproximadamente seis veces más gastos en relación con los pacientes de estancia prolongada ($3800 usd vs. 2 4000 usd). El 29.2% de los pacientes que tuvieron una estancia prolongada en la UCI, habrían requerido sólo un área de recuperación de fase II con una labor menos intensiva (step-down) debido al carácter menos severo de la enfermedad, tal cual lo pone de manifiesto la media baja de sus puntuaciones APACHE II [7.3 ± 2.6 (SD)] en comparación con la media general de la puntuación APACHE II (0.7 ± 7.5 (SD). CONCLUSIÓN: El estudio puso de relieve la necesidad de una unidad de recuperación de fase II (step-down) y un protocolo para transferir a los pacientes elegibles para esa unidad.

Outcome of elderly patients undergoing open-heart surgery in a developing country.

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8%. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31%) patients were above the age of 65 years. The mortality rate was 2.2% for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6%). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Outcome of elderly patients undergoing open-heart surgery in a developing country

To evaluate and compare the outcome of open-heart surgery in elderly patients with a concurrent group of younger patients in a developing country, data of all adult patients who underwent open-heart surgery during the period of 3 years from January 1999 to December 2001 were collected prospectively. Demographic data such as age and gender, other data such as preoperative diagnoses, comorbid illnesses, type of surgery, time of cardio-pulmonary bypass, length of stay and hospital outcome were recorded. The characteristics of patients above the age of 65 years were compared with a concurrent cohort of patients aged less than 65 years. One hundred and forty-five adult patients underwent open-heart surgeries in 3 years, and the overall mortality rate was 4.8 per cent. The much common surgeries were coronary artery bypass grafting, valve repair/replacement surgery and surgery for adult congenital heart diseases. Forty-five (31 per cent) patients were above the age of 65 years. The mortality rate was 2.2 per cent for patients who were aged 65 years and above, in comparison with that of the concurrent cohort of younger patients (6 per cent). This was probably because of more number of surgeries for congenital heart diseases in the latter group. However, even with other surgeries such as coronary artery bypass grafting, the elderly group of patients did equally well as the younger group. Elderly patients tolerate cardiac surgery well, and age should not be an exclusive criterion to decide against open-heart surgery.

Performance measurement of intensive care services in hospitals: the case of Barbados

The Intensive Care Unit (ICU), being one of those vital areas of a hospital providing clinical care, the quality of service rendered must be monitored and measured quantitatively. It is, therefore, essential to know the performance of an ICU, in order to identify any deficits and enable the service providers to improve the quality of service. Although there have been many attempts to do this with the help of illness severity scoring systems, the relative lack of success using these methods has led to the search for a form of measurement which would encompass all the different aspects of an ICU in a holistic manner. The Analytic Hierarchy Process (AHP), a multiple-attribute, decision-making technique is utilised in this study to evolve a system to measure the performance of ICU services reliably. This tool has been applied to a surgical ICU in Barbados; we recommend AHP as a valuable tool to quantify the performance of an ICU.

Outcome evaluation in a surgical intensive care unit in Barbados.

The performance of the Acute Physiology and Chronic Health Evaluation II scoring system was prospectively assessed in the surgical intensive care unit at the Queen Elizabeth Hospital, Barbados. A total of 309 patients admitted consecutively during a 2-year period (1999-2001) were evaluated. Demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation II score, duration of stay and hospital outcome were recorded. The predicted mortality for every patient and the costs incurred were also calculated. The overall observed mortality rate was 15.9% while the mean predicted mortality rate for our case-mix was 16.4%, which is comparable to results from developed countries. The cost incurred per patient was much lower at $13,636 (Barbados), compared to the patients' cost in North America ($60,000 Barbados).

Anesthesia outside the operating room for emergency procedures.

Non-anesthetists usually provide sedation and anesthesia outside the operating room for emergency procedures. Techniques vary from no sedation to deep sedation using drugs with a good safety profile and few side effects. Newer methods of airway control may allow volatile agents such as sevoflurane to be used. Anesthetists may need to join sedation teams if they are to maintain control of their specialty.

Terminology and the current limitations of time capnography: a brief review.

The carbon dioxide (CO2) trace versus time (time capnography) is convenient and adequate for clinical use. This is the method most commonly utilized in capnography. However, the current terminology in time capnography has not yet been standardized and is, therefore, a potential source of confusion. Standard terminology that is based on convention and logic to represent the various phases of a time capnogram is essential. The time capnogram should be considered as two segments: an inspiratory segment and an expiratory segment. The inspiratory segment is termed as phase ); the expiratory segment is divided into phases I, II, III, and, occasionally, IV. Phase I represents the CO2-free gas from the airways (anatomical dead space); phase II consists of a rapid S-shaped upswing on the tracing due to mixing of dead space gas with alveolar gas; and phase III, the alveolar plateau, represents CO2-rich gas from the alveoli. The physiologic basis of phase IV, the terminal upswing at the end of phase III, which is observed in capnograms recorded under certain circumstances (such as in pregnant subjects and obese subjects) is discussed in detail. The clinical implications of the alpha angle, which is the angle between phases II and III, and the beta angle, which is the angle between phases III and the descending limb of phase 0, are outlined. The subtle but important limitations of time capnography are reviewed; its current status as well as its future potential are explored.

Inspiratory valve malfunction in a circle system: pitfalls in capnography.

Capnography is a useful technique in monitoring the integrity of anaesthetic equipment such as the malfunctioning of unidirectional valves in circle system. However, the lack of a precise mechanism in existing capnographs to identify the start of inspiration and the beginning of expiration in the capnograms, makes the analysis of the carbon dioxide waveforms during inspiration difficult and thus results in inaccurate assessment of rebreathing. We report a case where, during the malfunction of the inspiratory unidirectional valve in the circle system, the capnograph failed to detect the presence of substantial rebreathing. Critical analysis of the capnogram recorded during the malfunction revealed that there was substantial rebreathing which was underestimated by the capnograph as it reports only the lowest CO2 concentration rebreathed during inspiration in such abnormal situations.

Anaesthesia without nitrous oxide

Nitrous oxide has a long history of successful use in inhalational anaesthesia. Nevertheless questions are being raised over possible deleterious effects which may complicate its routine use. As more potent volatile agents have become available, compressed air/oxygen mixtures are gradually replacing nitrous oxide as a carrier gas in inhalational anaesthesia. We recommend that compressed air be installed on all anaesthetic machines and that in future, machines be designed so as to make it impossible to administer both nitrous oxide and air simultaneously (AU)

Capnometry and anaesthesia.

In the last decade, capnography has developed from a research instrument into a monitoring device considered to be essential during anaesthesia to ensure patient safety. Hence, a comprehensive understanding of capnography has become mandatory for the anaesthetist in charge of patients in the operating room and in the intensive care unit. This review of capnography includes the methods available to determine carbon dioxide in expired air, and an analysis of the physiology of capnograms, which are followed by a description of the applications of capnography in clinical practice. The theoretical backgrounds of the effect of barometric pressure, water vapour, nitrous oxide and other factors introducing errors in the accuracy of CO2 determination by the infra-red technique, currently the most popular method in use, are detailed. Physiological factors leading to changes in end-tidal carbon dioxide are discussed together with the clinical uses of this measurement to assess pulmonary blood flow indirectly, carbon dioxide production and adequacy of alveolar ventilation. The importance of understanding the shape of the capnogram as well as end-tidal carbon dioxide measurements is emphasized and its use in the early diagnosis of adverse events such as circuit disconnections, oesophageal intubation, defective breathing systems and hypoventilation is highlighted. Finally, the precautions required in the use and interpretation of capnography are presented with the caveat that although no instrument will replace the continuous presence of the attentive physician, end-tidal carbon dioxide monitoring can be effective in the early detection of anaesthesia-related intraoperative accidents.

Should air-oxygen replace nitrous oxide-oxygen in general anaesthesia?

The use of compressed air-oxygen mixtures to replace nitrous oxide-oxygen in general anaesthesia was investigated in 378 patients. There were neither prolongations of recovery time nor instances of awareness under anaesthesia. The cost of general anaesthesia using compressed air-oxygen was about half that for nitrous oxide-oxygen mixtures.