An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa.

Background: With a shortage of intensive care unit (ICU) beds and rising healthcare costs in resource-limited settings, clinicians need to appropriately triage admissions into ICU to avoid wasteful expenditure and unnecessary bed utilisation. Objectives: To assess the nature, appropriateness and outcome of referrals to a tertiary centre ICU. Methods: A retrospective review of ICU consults from September 2016 to February 2017 at King Edward VIII Hospital was performed. The study was approved by the University of KwaZulu-Natal Biomedical Research Ethics Committee (BE291/17). Data pertaining to patients' demographics, referring doctor, diagnosis, comorbidities as well as biochemical and haemodynamic parameters were extracted. This information was then cross-referenced to the outcome of the ICU consultation. Data were descriptively analysed. Results: Five hundred consultations were reviewed over a 6-month period; 52.2% of patients were male and the mean age was 44 years. Junior medical officers referred 164 (32.8%) of the consultations. Although specialist supervision was available in 459 cases, it was only utilised in 339 (73.9%) of these cases. Most referrals were from tertiary (46.8%) or regional (30.4%) hospitals; however, direct referrals from district hospitals and clinics accounted for 20.4% and 1.4% of consultations, respectively. The appropriate referral pathway was not followed in 81 (16.2%) consultations. Forty-five percent of consults were accepted; however, 9.3% of these patients died before arrival in ICU. A total of 151 (30.2%) patients were refused ICU admission, with the majority (57%) of these owing to futility. Patients were unstable at the time of consult in 53.2% of referrals and 34.4% of consults had missing data. Conclusion: Critically ill patients are often referred by junior doctors without senior consultation, and directly from low-level healthcare facilities. A large proportion of ICU referrals are deemed futile and, of the patients accepted for admission, almost 1 in 10 dies prior to ICU admission. More emphasis needs to be placed on the training of doctors to appropriately triage and manage critically ill patients and ensure appropriate ICU referral and optimising of patient outcomes. Contributions of the study: There is a paucity of information related to ICU referrals in South Africa. The nature, appropriateness and outcomes of referrals to a tertiary ICU is discussed in this study.

The utility of brain natriuretic peptide as a prognosticating marker in critical care patients.

Background: Brain natriuretic peptide (BNP) is an established biomarker of morbidity and mortality in cardiac failure. Data also suggest potential prognostic utility in non-heart failure cohorts. The utility of BNP in predicting intensive care unit (ICU) outcomes has not been well evaluated in a mixed critical care population in the South African (SA) context. Objectives: To evaluate the ability of BNP to predict ICU mortality in a heterogeneous critical care population in SA. Methods: This was a retrospective observational study of 100 patients admitted to a multidisciplinary, closed, intensivist-run ICU in a tertiary academic hospital serving KwaZulu-Natal Province (1 January 2020 - 31 July 2022). Initial BNP was evaluated as a predictor of ICU mortality using univariate and multivariable analyses. Results: There was a statistically significant difference in BNP between survivors and non-survivors in the cohort of patients without heart failure. The median initial BNP in the non-heart failure cohort was 411 (interquartile range (IQR) 116 - 848) ng/L in non-survivors, and 150 (44 - 356) ng/L in survivors (p=0.028). The optimal cut-off for BNP was determined as 366 ng/L. A BNP ≥366 ng/L was an independent predictor of ICU outcome. Conclusion: This study highlights the potential utility of BNP as a predictor of ICU mortality in a heterogeneous ICU population, with the greatest utility in patients without heart failure. Further studies are required to confirm this finding. Contribution of the study: The study is a retrospective, observational study conducted in multidisciplinary, closed, intensivist-run ICU at a tertiary academic hospital. It showed an elevated BNP is associated with increased ICU mortality, particularly in those without a baseline diagnosis of heart failure. This identifies the need for further prospective studies evaluating BNP as a prognostic marker in non-cardiac critically ill patients, and its utility as an addition in pre-existing ICU outcome prediction scores.

Core competencies in critical care for general medical practitioners in South Africa: A Delphi study.

Background: Despite a high burden of disease that requires critical care services, there are a limited number of intensivists in South Africa (SA). Medical practitioners at district and regional public sector hospitals frequently manage critically ill patients in the absence of intensivists, despite these medical practitioners having had minimal exposure to critical care during their undergraduate training. Objectives: To identify core competencies in critical care for medical practitioners who provide critical care services at public sector hospitals in SA where intensivists are not available to direct patient management. Methods: A preliminary list of core competencies in critical care was compiled. Thereafter, 13 national and international experts were requested to achieve consensus on a final list of core competencies that are required for critical care by medical practitioners, using a modified Delphi process. Results: A final list of 153 core competencies in critical care was identified. Conclusion: The core competencies identified by this study could assist in developing training programmes for medical practitioners to improve the quality of critical care services provided at district and regional hospitals in SA. Contribution of the study: The study provides consensus on a list of core competencies in critical care that non-intensivist medical practitioners managing critically ill patients in healthcare settings in South Africa, especially where intensivists are not readily available, should have. The list can form the core content of training programmes aimed at improving critical care competence of general medical practitioners, and in this way hopefully improve the overall outcomes of critically ill patients in South Africa.

Early catecholamine dose as a predictor of outcome among patients in a multidisciplinary intensive care unit.

BACKGROUND: Vasoactive and/or inotropic agents are used in the management of patients with circulatory shock. It is a clinical perception that mortality in critically ill patients increases with increasing doses of inotropes and/or vasopressors; however, the clinical significance of catecholamine doses early in the management of critically ill patients has not been investigated well, especially in the South African (SA) context. Arbitrary 'maximum' doses of catecholamine therapy are used that are not evidence based. This study will help clinicians by either showing that there is no clear cut-off beyond which survival is unlikely or by identifying a dose of inotropic support above which survival is unlikely. This article provides clinicians with an evidence base against which to direct their therapy. OBJECTIVES: To describe the inotropic prescribing practices in a heterogeneous population of shocked critically ill patients in a tertiary intensive care unit (ICU) in SA, establish an association between inotropic dose and outcome and ascertain the nature of this association. METHODS: This was a retrospective observational study of 189 patients admitted to a multidisciplinary academic ICU. The admission, 24-hour and maximum inotrope doses were collected and analysed, and these and other biochemical and clinical parameters were evaluated as predictors of mortality. RESULTS: A total of 189 patients met the study inclusion criteria. The overwhelming majority of patients (99%) received adrenaline, with only 7% of those requiring inotropes receiving noradrenaline. Median inotrope dose at admission, 24-hour dose and maximum dose in the first 24 hours were all significantly higher in non-survivors than survivors. ICU mortality increased with increasing inotrope dose, and an inotrope dose ≥60 µg/min on admission was associated with an ICU mortality of 89%, with the same cut-off at 24 hours being associated with a mortality of 89%. Survivors at doses >80 µg/min were only noted among trauma patients. CONCLUSIONS: High early inotrope doses are associated with increasing ICU mortality. The findings highlight the need for further research on the clinical use of inotrope dose in risk stratification in the critical care environment. The current results call into question the routine provision of high-dose inotropic support in non-trauma patients.

Acute poisonings presenting to King Edward VIII hospital intensive care unit in Durban, South Africa.

Background: Acute poisoning is a potentially preventable burden on the healthcare systems and a significant cause of morbidity and mortality worldwide. Improved knowledge of the patterns of poisoning, the clinical course and outcomes of these cases may help create better preventive and management approaches. Objectives: To describe the demographics, clinical characteristics and outcomes of patients with acute poisonings who were admitted to a multidisciplinary intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa. Methods: A retrospective observational chart review of patients admitted to the study ICU with acute poisoning over a 24-month period (1 July 2015 - 30 June 2017). Results: A total of 85 patients with acute poisoning were admitted to the ICU during the study period. There was a female preponderance (55%) with a median age of 28 years. ICU mortality was 16.5% with a median ICU length of stay of 3 days. Tricyclic antidepressants (TCA) were the most common toxin identified (16.5%). The ingestion of amphetamines was associated with a statistically significant increase in mortality (100.0% v. 13.4%; p=0.04). Ethylene glycol was a commonly ingested toxin (9.4% of admissions) and had a high mortality rate of 37.5% that was not statistically significant (p=0.121). Referral for inotropic support, a Glasgow Coma Scale ≤5 and metabolic acidosis on admission were associated with higher ICU mortality. Conclusion: Acute poisoning results in potentially preventable ICU admission and mortality. TCA poisoning was the most common presentation and this warrants review of TCA prescription practice. Ingestion of illicit drugs, ethylene glycol or presentation with a markedly reduced level of consciousness, shock or metabolic acidosis should alert treating physicians to a possible elevated risk of adverse outcomes. Contributions of the study: This is the first study to describe acute poisoning patterns in KwaZulu-Natal from a critical care perspective. This will increase knowledge of common toxins and the presentations that lead to critical care referral. Furthermore, prescription practices for common toxins like TCAs need to be reviewed as a prevention strategy.

Renal replacement therapy in intensive care units in KwaZulu-Natal Province, South Africa.

Background: Renal replacement therapy (RRT) is a scarce resource in southern Africa. Critically ill patients are at risk of developing acute kidney injury (AKI), which may require RRT. There are few data on the utilisation of RRT in southern African intensive care units (ICUs). Objectives: To determine the indications for initiating RRT in critically ill patients in ICUs in KwaZulu-Natal, South Africa (SA) and to describe the methods and dosing of RRT. Methods: A prospective observational study was performed to investigate the indications for initiating, methods and dosing of RRT among patients admitted to four ICUs in KwaZulu-Natal Province, SA. All adult patients were eligible for inclusion. Results: A total of 108 patients who received RRT were included in the study. The most common reasons for initiation of RRT were a high/rising creatinine, high/rising urea, acidosis and fluid balance. The majority of the patients (79.6%; n=86) had three or more indications for RRT. A total of 353 intermittent haemodialysis/slow low-efficiency dialysis (IHD/SLED) sessions and 84 continuous renal replacement therapy (CRRT) sessions were recorded. The median (interquartile range (IQR)) CRRT dose was 25.8 (19.1 - 28.8) mL/kg/h. The median (IQR) urea reduction ratio for IHD/SLED was 32.4% (15.0 - 49.8). Conclusion: Patients in this study had multiple indications for initiating RRT. The dosing of RRT was not optimal, with a wide range shown in CRRT, and the majority of patients did not achieve a urea reduction ratio (URR) >65%. Contributions of the study: Renal replacement therapy is a scarce resource in Africa. Little is known about the current types and dosing of RRT in critical care units in South Africa. We showed that critically ill patients had multiple indications for RRT and the dosing was not optimal.

South African guidelines on the determination of death.

Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/). Key points • Brain death and circulatory death are the accepted terms for defining death in the hospital context. • Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. • The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation. • Brain-death testing while on extra-corporeal membrane oxygenation is outlined. • Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. • The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

South African guidelines on the determination of death.

Summary: Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence. The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment (https://criticalcare.org.za/resource/death-determination-checklists/). Key points: Brain death and circulatory death are the accepted terms for defining death in the hospital context.Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met.The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks' corrected gestation.Brain-death testing while on extra-corporeal membrane oxygenation is outlined.Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation.The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa.

Letter by Gopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodley.

An evaluation of feeding practices and determination of barriers to providing nutritional support in a multidisciplinary South African intensive care unit.

Background: Adequate nutritional support is crucial to optimising intensive care unit (ICU) outcomes. Objectives: To assess adherence to current nutritional guidelines in critically ill patients in South Africa (SA). To identify risk factors for non-adherence to guideline. Methods: Retrospective observational chart review of nutritional practices, from 1 December 2017 to 31 May 2018, during the first week of ICU admission in adult patients admitted to a tertiary, multidisciplinary ICU in Durban, SA, for >48 hours. Results: The study cohort (N=150) had a median age of 39 years and an ICU mortality of 28%. Surgical patients accounted for 50.7% of admissions. Ninety-eight percent of patients received mechanical ventilation, 75% required inotropic support, and 56% had acute kidney injury. The median time to initiation of enteral nutrition (EN) was 3 days, with EN being initiated within 48 hours in 39% of patients, and by day 7 80% of patients had received EN. Goal feeds were reached in 23% of patients by discharge, death or day 7. Parenteral nutrition was initiated in 16.7% of patients. There was an association between shock, acute kidney injury, increasing sequential organ failure assessment score and inotrope dose, and failure to initiate EN. Failure to initiate EN was predominantly due to unavoidable factors, but a number of clinical and administrative areas were identified to improve EN delivery. Conclusion: Adequate nutrition is associated with reduced morbidity, ICU length of stay, mortality and improved functional outcomes. More attention to avoiding barriers to adequate ICU nutrition and enhanced adherence to feeding protocols should be encouraged. Contributions of the study: This study significantly adds to the limited data available from sub- Saharan Africa on nutritional practices in critical care, and in particular barriers to provision of EN. It is further anticipated that the findings of the study will contribute in making recommendations in an attempt to improve the outcomes.

Critical Care Society of Southern Africa adult patient blood management guidelines: 2019 Round-table meeting, CCSSA Congress, Durban, 2018.

The CCSSA PBM Guidelines have been developed to improve patient blood management in critically ill patients in southern Africa. These consensus recommendations are based on a rigorous process by experts in the field of critical care who are also practicing in South Africa (SA). The process comprised a Delphi process, a round-table meeting (at the CCSSA National Congress, Durban, 2018), and a review of the best available evidence and international guidelines. The guidelines focus on the broader principles of patient blood management and incorporate transfusion medicine (transfusion guidelines), management of anaemia, optimisation of coagulopathy, and administrative and ethical considerations. There are a mix of low-middle and high-income healthcare structures within southern Africa. Blood products are, however, provided by the same not-for-profit non-governmental organisations to both private and public sectors. There are several challenges related to patient blood management in SA due most notably to a high incidence of anaemia, a frequent shortage of blood products, a small donor population, and a healthcare system under financial strain. The rational and equitable use of blood products is important to ensure best care for as many critically ill patients as possible. The summary of the recommendations provides key practice points for the day-to-day management of critically ill patients. A more detailed description of the evidence used to make these recommendations follows in the full clinical guidelines section.

Low albumin levels are associated with mortality in the critically ill: A retrospective observational study in a multidisciplinary intensive care unit.

Background: Albumin is a determinant of plasma colloid oncotic pressure and buffering capacity. It is a carrier protein for drugs and is important for normal functioning of the glycocalyx. Hypoalbuminaemia is common in the critically ill and has been associated with adverse outcomes. The association between hypoalbuminaemia and outcome has not been specifically explored in the South African context. Objectives: To determine whether albumin levels on admission and changes in albumin levels were associated with intensive care unit (ICU) mortality in a heterogenous critically ill population. Methods: This was a retrospective observational study of 247 adult patients who were admitted to a multidisciplinary ICU. Albumin levels were measured on admission and 48 hours later, alongside other biochemical and clinical parameters to determine whether they were predictive of ICU mortality. Results: The lowest level of albumin on admission was 8 g/L and the highest was 43 g/L. The incidence of hypoalbuminaemia (using the laboratory reference range) was 93.9% on admission and 99.4% at 48 hours. Receiver operating characteristic curve analysis provided an optimal albumin cut-off of 18.5 g/L. Using this cut-off, hypoalbuminaemia at admission and at 48 hours was associated with increased ICU mortality. Hypoalbuminaemia at admission was an independent predictor of mortality using multivariable analysis (OR 3.74; 95% confidence interval 1.87 - 4.48). Conclusion: Hypoalbuminaemia is associated with increased ICU mortality. There is currently no evidence to support the use of albumin replacement therapy. Further research is required to determine its role in critically ill patients. Contributions of the study: Hypoalbuminaemia is common in critically ill South African (SA) patients and is associated with increased ICU mortality. This has not been well explored in the SA setting. We found that an optimal albumin cut-off was 18.5 g/L, which was much lower than the limits of the laboratory reference range.

The incidence and outcomes of patients with acute kidney injury in a multidisciplinary intensive care unit in Durban, South Africa.

Background: Acute kidney injury (AKI) in critically ill and resource-limited settings is under investigated. Objectives: To describe the incidence, outcomes and healthcare burden of AKI in a multidisciplinary intensive care unit (ICU) in Durban, South Africa (SA). Methods: All adult patients admitted to the ICU at King Edward VIII Hospital from January 2016 to June 2016, who did not have end-stage renal disease and survived for more than 6 hours after admission were evaluated for AKI using the kidney disease improving global outcomes (KDIGO) creatinine criteria. Potential risk factors for AKI and an association between AKI and outcomes including ICU mortality and length of stay were analysed. Results: We screened 204 patients for inclusion into the study and 26 patients were excluded. About half of the patients (50.5%; n=90/178) who were included in the study were diagnosed with AKI at the time of admission and 16.3% (n= 29/178 developed AKI in the ICU. Among the patients who had AKI on admission, 50% (n=45/90) were classified as KDIGO stage1, 21.1% (n=19/90) as stage 2 and 28.8% (n=26/90) as stage 3. Less than one-third (24.7%; n=44/178) of the patients who developed AKI in the ICU were classified as KDIGO stage 1, 14% (n=25/178) were stage 2, and 28% (n=50/178) were stage 3. The mortality rate for patients with AKI on admission was 40.0% (n=36/90) compared with 39.8% (n=35/88) for those without AKI on admission (p=0.975). The mortality rate for all patients with AKI was 46.2% (n=55/119) compared with 27.1% (n=16/59) in patients who did not develop AKI (p=0.014). Conclusion: AKI is common in critically ill patients presenting to a tertiary ICU in Durban, SA. AKI is associated with increased mortality and length of stay in the ICU. Strategies to prevent the development or worsening of AKI must be emphasised. These include prevention or at least early treatment of sepsis, adequate fluid resuscitation, aggressive haemodynamic optimisation and avoidance of nephrotoxins. This is especially important in settings where there is limited access to renal replacement therapy (RRT). Contributions of the study: This is one of the first studies to describe the incidence and outcomes of AKI in a general critical care population in a resource-limited setting. The study highlights that AKI is very common in critically ill patients in a resource-limited setting, and is associated with increased mortality and resource utilisation. It also highlights the importance of sepsis as a risk factor for AKI.

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit.

BACKGROUND: When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context. OBJECTIVES: To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care. METHODS: A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors. RESULTS: A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease. CONCLUSIONS: A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors.

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital - a 4-year retrospective review.

Background: Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients. Objectives: To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith. Methods: The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death). Results: The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia. Conclusion: The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management. Contributions of the study: The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.

The utility of hyperlactataemia in the definition of septic shock: evaluating the Sepsis-3 definitions in a sub-Saharan African intensive care unit

Background. Sepsis-3 definitions were published in 2016 and included hyperlactataemia (serum lactate >2.0 mmol/L) as a mandatory component of the new definition of septic shock. These data were collected mainly from high-income countries and lack adequate validation in scenarios outside these countries.Objectives. To evaluate admission serum lactate as a predictor of intensive care unit (ICU) mortality in patients with infection and hypotension requiring inotropic support.Methods. This was a retrospective observational study of 170 patients with infection and hypotension requiring inotropic support admitted to the ICU at King Edward VIII Hospital in Durban, South Africa. Admission serum lactate was evaluated as a predictor of ICU mortality in this cohort.Results. The study population had a median age of only 42 years. The ICU mortality rate for the cohort was 49.4%. Most patients were surgical (71.8%), with the most common source of sepsis being abdominal (55.9%). The ICU mortality rate was 40.9% in patients with a lactate level ≤2.0 mmol/L and 52.4% in those with a level >2.0 mmol/L; this did not reach statistical significance. The optimal cut-off was 4.5 mmol/L, at which there was a clear, statistically significant difference in mortality between patients without (39.3%) and with hyperlactataemia (59.3%)(p=0.009).Conclusions. Hyperlactataemia was associated with increased mortality. However, a lactate level >2.0 mmol/l, as proposed in Sepsis-3, did not reach statistical significance, and a higher cut-off of >4.5 mmol/L was more appropriate

Factors influencing decisions to admit or refuse patients entry to a South African tertiary intensive care unit

Background. When critically ill patients with life-threatening conditions need urgent, expensive, life-sustaining care, admission and triage decision-making may be extremely challenging as critical care practitioners strive to balance these high-stakes, high-stress, time-sensitive decisions against a limited resource. The factors affecting the decision to admit or refuse a patient entry to an intensive care unit (ICU) have not been described in the South African (SA) context.Objectives. To identify and describe the factors that influence ICU triage decision-making for patients referred to a regional/tertiary facility for intensive care.Methods. A retrospective review of recorded data from January 2014 to December 2017 was conducted for all referrals to the 12-bed, intensivist-led, closed general ICU at King Edward VIII Hospital, an 800-bed tertiary public facility in KwaZulu-Natal Province, SA. Data were extracted to identify factors associated with the decision to admit or refuse patients referred to the unit. Significant factors on univariate analysis were then included in a multivariable analysis using binary logistic regression to identify significant independent factors.Results. A total of 4 469 referrals were received over the 48-month period studied. Of these, 507 (11.3%) were withdrawn before a final decision of acceptance or refusal and 94 (2.1%) had an unknown outcome, leaving 3 868 referrals where an acceptance/refusal decision was made as our study cohort. Of these, 38.7% were refused admission. The commonest reason for refusal (57.0%) was assessment of the patient as 'too sick' by the admitting specialist. Multivariable analysis identified age, referring discipline as medicine, poor or unknown premorbid functioning, and comorbidities of HIV, malignancy and cardiac failure as significant factors for refusal of admission to the ICU. Referrals were significantly more likely to be accepted from private institutions, and if the comorbidity was asthma or psychiatric disease.Conclusions. A better understanding of factors affecting ICU admission/refusal decisions will allow for a more effective and appropriate referral process and more rational utilisation of scarce ICU resources. Further prospective studies are necessary to elucidate fully the impact of various other factors

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital ­ a 4-year retrospective review

Background. Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients. Objectives. To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith. Methods. The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death). Results. The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia. Conclusion. The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management