Comparison of glottic views and intubation times in the supine and 25 degree back-up positions.

BACKGROUND: We explored whether positioning patients in a 25° back-up sniffing position improved glottic views and ease of intubation. METHODS: In the first part of the study, patients were intubated in the standard supine sniffing position. In the second part, the back of the operating table was raised 25° from the horizontal by flexion of the torso at the hips while maintaining the sniffing position. The best view obtained during laryngoscopy was assessed using the Cormack and Lehane classification and Percentage of Glottic Opening (POGO) score. The number of attempts at both laryngoscopy and tracheal intubation, together with the use of ancillary equipment and manoeuvres were recorded. The ease of intubation was indirectly assessed by recording the time interval between beginning of laryngoscopy and insertion of the tracheal tube. RESULTS: Seven hundred eighty one unselected surgical patients scheduled for non-emergency surgery were included. In the back-up position, ancillary laryngeal manoeuvres, which included cricoid pressure, backwards upwards rightward pressure and external laryngeal manipulation, were required less frequently (19.6 % versus 24.6 %, p = 0.004). The time from beginning of laryngoscopy to insertion of the tracheal tube was 14 % shorter (median time 24 versus 28 s, p = 0.031) in the back-up position. There was no significant difference in glottic views. CONCLUSIONS: The 25° back-up position improved the ease of intubation as judged by the need for fewer ancillary manoeuvres and shorter time for intubation. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02934347 registered retrospectively on 14th Oct 2016.

Uncertainty in end-of-life care.

PURPOSE OF REVIEW: Uncertainty surrounding medical decision-making is particularly important during end-of-life decision-making. Doubts about the patient's best interests and prognostic accuracy may lead to conflict. RECENT FINDINGS: Many authors have suggested recently that medical attitudes to uncertainty need review. It is inappropriate to avoid discussion of uncertainty during end-of-life care and American literature suggests that patients and families accept uncertainty in end-of-life discussions. Recently, authors have advocated the concept of 'Practical Certainty' accepting that absolute certainty is rarely possible in end-of-life decision-making and openly acknowledging that the physicians are as certain as they can be in the circumstances. Allowing time to provide acceptance of a palliative care pathway and using the collective wisdom of colleagues improves the accuracy of prediction and reduces conflict at the end of life. SUMMARY: The implications of this review are that doctors should not avoid discussing uncertainty in end-of-life conversations and the article provides some recommendations for minimizing conflict arising from end-of-life discussion.

Uncertainty in end-of-life care and shared decision making.

Assessing the appropriateness of continuing life support is a difficult task for intensive care unit staff. Part of this difficulty relates to prognostic uncertainty and the varying reliability of clinical decisions. Uncertainty about prognosis is quickly recognised by patients and families, and can be a source of mistrust and potential conflict. We discuss the reasons for uncertainty and outline key measures to reduce and manage such uncertainty. Practical certainty, where the clinicians are as certain as they can be, with both prognostication and knowledge of patient wishes, may be an appropriate concept for physicians engaged in end-of-life decisions. It involves accurate prognostication, informed surrogates, advance care planning, time to assess response, and the collective wisdom of experienced clinicians. The family conference should develop an agreed plan through shared decision making. The collective wisdom of experienced health care workers with good communication skills and informed patient advocates increases the likelihood of achieving practical certainty and the best decisions. However, greater time and effort seems to be required to improve end-of-life care in the ICU.

Cost-Drivers in Acute Treatment of Severe Trauma in Europe: A Systematic Review of Literature.

INTRODUCTION: Throughout the world, trauma is a leading cause of morbidity and mortality in the young and most active group of society. While specialist trauma centers play a critical role in the survival after severe trauma, the assessment of trauma-related costs, budgeting for adequate trauma capacity, and determining the cost-effectiveness of interventions in critical care are fraught with difficulties. Through a systematic review of the European literature on severe trauma, we aimed to identify the key elements that drive the costs of acute trauma care. METHODS: A PubMed/MEDLINE search for articles relating the costs and economics of trauma was performed for the period January 1995 to July 2007. One hundred and seventy-three European publications were identified. Twelve publications were retrieved for complete review that provided original cost data, a breakdown of costs according to the different elements of trauma care, and focused on severe adult polytrauma. The identified publications presented studies from the UK (3), Germany (6), Italy (2), and Switzerland (1). RESULTS: In all publications reviewed, length of stay in the intensive care unit (ICU; 60%) and requirements for surgical interventions (≤ 25%) were the key drivers of hospital costs. The cost of transfusion during the initial rescue therapy can also be substantial, and in fact represented a significant portion of the overall cost of emergency and ICU care. Multiple injuries often require multiple surgical interventions, and prolonged ICU and hospital stay, and across all studies a clear relationship was observed between the severity of polytrauma injuries observed and overall treatment costs. While significant differences existed in the absolute costs of trauma care across countries, the key drivers of costs were remarkably similar. CONCLUSIONS: Irrespective of the idiosyncrasies of the national healthcare systems in Europe, severity of injury, length of stay in ICU, surgical interventions and transfusion requirements represent the key drivers of acute trauma care for severe injury.

Outcomes and costs of penetrating trauma injury in England and Wales.

BACKGROUND: Penetrating trauma injury is generally associated with higher short-term mortality than blunt trauma, and results in substantial societal costs given the young age of those typically injured. Little information exists on the patient and treatment characteristics for penetrating trauma in England and Wales, and the acute outcomes and costs of care have not been documented and analysed in detail. METHODS: Using the Trauma Audit Research Network (TARN) database, we examined patient records for persons aged 18+ years hospitalised for penetrating trauma injury between January 2000 and December 2005. Patients were stratified by injury severity score (ISS). RESULTS: 1365 patients were identified; 16% with ISS 1-8, 50% ISS 9-15, 15% ISS 16-24, 16% ISS 25-34, and 4% with ISS 35-75. The median age was 30 years and 91% of patients were men. Over 90% of the injuries occurred in alleged assaults. Stabbings were the most common cause of injury (73%), followed by shootings (19%). Forty-seven percent were admitted to critical care for a median length of stay of 2 days; median total hospital length of stay was 7 days. Sixty-nine percent of patients underwent at least one surgical procedure. Eight percent of the patients died before discharge, with a mean time to death of 1.6 days (S.D. 4.0). Mortality ranged from 0% among patients with ISS 1-8 to 55% in patients with ISS>34. The mean hospital cost per patient was pound 7983, ranging from pound 6035 in patients with ISS 9-15 to pound 16,438 among patients with ISS>34. Costs varied significantly by ISS, hospital mortality, cause and body region of injury. CONCLUSION: The acute treatment costs of penetrating trauma injury in England and Wales vary by patient, injury and treatment characteristics. Measures designed to reduce the incidence and severity of penetrating trauma may result in significant hospital cost savings.

Outcomes and costs of blunt trauma in England and Wales.

BACKGROUND: Trauma represents an important public health concern in the United Kingdom, yet the acute costs of blunt trauma injury have not been documented and analysed in detail. Knowledge of the overall costs of trauma care, and the drivers of these costs, is a prerequisite for a cost-conscious approach to improvement in standards of trauma care, including evaluation of the cost-effectiveness of new healthcare technologies. METHODS: Using the Trauma Audit Research Network database, we examined patient records for persons aged 18 years and older hospitalised for blunt trauma between January 2000 and December 2005. Patients were stratified by the Injury Severity Score (ISS). RESULTS: A total of 35,564 patients were identified; 60% with an ISS of 0 to 9, 17% with an ISS of 10 to 16, 12% with an ISS of 17 to 25, and 11% with an ISS of 26 to 75. The median age was 46 years and 63% of patients were men. Falls were the most common cause of injury (50%), followed by road traffic collisions (33%). Twenty-nine percent of patients were admitted to critical care for a median length of stay of 4 days. The median total hospital length of stay was 9 days, and 69% of patients underwent at least one surgical procedure. Seven percent of the patients died before discharge, with the highest proportion of deaths among those in the ISS 26-75 group (32%). The mean hospital cost per person was 9,530 pounds sterling (+/- 11,872). Costs varied significantly by Glasgow Coma Score, ISS, age, cause of injury, type of injury, hospital mortality, grade and specialty of doctor seen in the accident and emergency department, and year of admission. CONCLUSION: The acute treatment costs of blunt trauma in England and Wales vary significantly by injury severity and survival, and public health initiatives that aim to reduce both the incidence and severity of blunt trauma are likely to produce significant savings in acute trauma care. The largest component of acute hospital cost is determined by the length of stay, and measures designed to reduce length of admissions are likely to be the most effective in reducing the costs of blunt trauma care.

The recognition and early management of critical illness.

INTRODUCTION: Critical illness is an emergency because the inflammatory response has redundant multiple pathways; once triggered, it is difficult to control or suppress. Infection is a potent precursor of critical illness and increasing organ dysfunction has a synergistic, rather than purely additive, adverse effect on mortality. The longer the inflammatory process continues unabated, the more advanced and unrecoverable the pathophysiological processes become resulting in a high mortality. METHODS: The review is a statement of the author's opinion supported by selected references. The content of the review was presented as the Tutor Edwards Lecture at The Royal College of Surgeons of England in December 2004. RESULTS: Critical illness is preceded by prodromal signs warning of impending physiological catastrophe. These simple physiological signs, the most sensitive of which is the respiratory rate can be quantified using Early Warning Scores. If patients trigger the Early Warning Score, emergency management is required to reverse the abnormal physiological decline or to prompt admission to a critical care area. The emergency management principles include removal or reversal of the cause so shutting down the inflammatory response, appropriate antibiotic therapy and general organ support. CONCLUSIONS: Formalising measurement of physiological (in)stability on the general ward using Early Warning Scores improves recognition of unstable and potentially critically ill patients. Prompt intervention will either reverse further physiological decline or facilitate timely referral to the critical care service for further, more invasive, organ support.