Trauma admissions to the Intensive Care Unit of the University Hospital of the West Indies, Kingston 7, Jamaica [abstract]

OBJECTIVE: Trauma is the single most common reason for admission to the surgical wards at the 500-bed University Hospital of the West Indies in Kingston, Jamaica. This study was undertaken to assess the impact of trauma on the Intensive Care Unit (ICU) in terms of time, resources, staffing and cost. It also assesses the pattern profile, frequency and outcome of trauma cases admitted to the multidisciplinary 8-bed ICU. METHODS: Records of all trauma patients admitted to the ICU over a period of a 5-year period between October 1995 and September 2000 were reviewed. Approval for this study was obtained from the institutional ethics committee. Data collected included age, gender, diagnosis, cause of trauma, referring specialities, duration of admission and outcome. RESULTS: During the study period 161 patients with severe trauma were admitted to the ICU, representing 12 percent and 16 percent of total and emergency ICU admission, respectively. There was a preponderance of men (M:F = 4:1), and they were generally younger than the average ICU patient (mean age 35 vs. 42 years). Trauma admission were almost exclusively emergencies (98 percent) and came mainly from the operating theatre/recovery room (67.3 percent) and Accident and Emergency (16.4 percent). The length of ICU stay of all trauma patients was a mean (SD) of 6.3 (8.4) days. More than one-half of the non-survivors (55 percent) died within 24 hours of ICU admission and 84 percent died by 7th ICU day. Road traffic accidents remain the leading cause of severe trauma (45 percent), but there was also a high prevalence of intentional and interpersonal violence (42 percent). CONCLUSION: Severe trauma in Jamaica is a major cause of hospitalization and intensive care utilization, and hence consumes a significant amount of already under-funded healthcare budget. In most instances it is preventable. Trauma prevention is therefore the most effective management. The need for a high dependency unit and expansion of the existing ICU is also underscored. (AU)

Vomiting post tonsillectomy with or without other upper airway and/or aural procedures

OBJECTIVE: The incidence of vomiting post tonsillectomy has been quoted to be 30-73 percent. Vomitting can cause considerable patient suffering. Our aim was to assess the incidence at this institution and to determine its effects and casual factors in our patient population. METHODS: This study was conducted both retro- and prospectively over the period January 1, 2000 to December 31, 2000. The medical records of all patients who underwent tonsillectomy with or without upper airway or aural procedure/s were reviewed. Data collected included: age, gender, body weight, diagnosis, premedication, type of induction of anaesthesia, blood loss, duration of anaesthesia and recovery room stay, peri-operative analgesia, antibiotic, steroid, atropine and anti-emetic administration. Approval from the institutional ethics committee was obtained. RESULTS: A total of 76 patients underwent tonsillectomy during the study period. The medical records of 75 of these patients were reviewed. The age range for the study sample was 10 months to 38 years. The majority, 66 of the patients, were children (<13 years) and hence they accounted for 88 percent of the study sample. Most were in the 0-5 year-age group and accounted for 57 percent of the study sample. Thirteen patients (17 percent of the study sample) vomited. Most of the vomiters (nine) were in the 0-5-year-age group, three in the 6-12-year-age group, and one in the adult group. Overall, there were equal numbers of male and female vomiters. CONCLUSION: Opioid analgesia (pethidine) was a significant risk factor for vomiting, while trimeprazine tartrate (a premedicant) and steroid were significant preventive factors. Studies have shown that one dose of dexamethasone (administered pre- or intra-operatively) decreases vomiting as well as the need for analgesia (especially opioid) post-operatively. There is therefore the need for a follow-up study to assess the effect of dexamethasone in this patient population. (AU)

Severe neurological complications of post open heart surgery: the Jamaican experience; January, 1994 - August, 1999

Neurological complications after open-heart surgery (OHS) constitute a broad spectrum of injury, and represents the leading cause of morbidity and mortality. The most serious injury is seen in those who remain comatose or never regain meaningful neurologic function. Stroke is another devastating complication that can leave the patient permanently disabled. The incidence of stroke has been documented as ranging from 0.8 - 5.2 percent. Much less information is available on the incidence of the less fatal complications such as delirium, confusion, encephalopathy, developmental delay or other neuropsychiatric disorders. During the period January, 1994 to August, 1999, a total of 360 paitents (adults and children) underwent OHS, at the University Hospital of the West Indies (UHWI), Mona, Jamaica. The types of surgeries performed were: ASD = 53; VSD = 40; valve replacement = 151 (100 MVR, 34 AVR, 17 DVR); valvuloplasty/annuloplasty = 5; CABG = 44; repair of congenital heart abnormalities = 65; other (atrial myxoma) = 2. About eight (8) patients (2.2 percent) developed severe neurological symptoms post-operatively. These ranged from short period (<24 hours) of seizure activities to severe encephalopathy and death, secondary to massive cerebral infarction. Four (4) of these patients died as a result of the neurologic complication. There is no need for avoidance and/or elimination of the factors that increase the risk of post-operative neurologic complications. Unfortunately not all of these can be eliminated. There is also the need for detailed, structured neurological and neuropsychiatric assessments, both pre- and post-operatively. These will enable the early detection of gross, but more importantly the subtle changes and hence prompt institution of counteractive/corrective measure. Detection of markers which will indicate the possible development of severe neurologic injury would also be useful.(AU)

Nasal non-invasive positive pressure ventilation

This case report is presented to illustrate the advantages of Nasal Non-Invasive Positive Pressure Ventilation (NNIPPV). It is relatively simple, practical, easy to use, and has been proven to be an efficient means of treatment for patients with chronic respiratory failure (CRF), especially hypercanic respiratory failure. The availability of NNIPPV has increased in recent years and has made the concept of domiciliary ventilatory support a practical reality. It has resulted in decreased frequency and duration of hospital admission and hence minimised certain demands on the health service. The use of NNIPPV should be encouraged in developing countries where a shortage of health personnel (especially nurses) and limited health care budgets exists (AU)

Severe Neurological complications post-open heart surgery: the Jamacian experience

During the period January 1994 to December 1999, a total of 395 patients - adults and children - underwent various types of open heart surgical (OHS) procedures. The range of these patients was 10 days to 77 years. Most (43.5 percent) of these patients underwent valve replacement - first time and "redo" - as a result of rheumatic heart disease of varying duration and severity. The other large group was the complex congenital heart abnormalities (16 percent), followed by the group that underwent repair of atrial septal defect (13 percent), coronary artery bypass graft (13 percent) and repair of the ventricular septal defect (12 percent). Open valve repair (2 percent) developed severe neurological complications (NCs) post-OHS. These included: a short period (< 48 hours) of irritability and fluctuating consiousness level; seizure activity associated with hemiparesis and/or blindness; severe encephalopathy and vegetative state. Four patients showed complete recovery, but one died as a result of complications of the anti-seizure medication. Of the five, four died as a result of the NCs, and one was discharged in a vegetative state. Such severe neurological complications after an otherwise successful cardiac surgery represented a devastating outcome for patients and their families, and the social and economic impacts are enormous. Several factors were identified. The main ones being mitral valve replacement (MVR), especially "redo" surgery, female gender, age over 60 years, high New York Association functional class and post-operative hypotension. However, the true incidence of NCs (gross and subtle) in the study group cannot be ascertained. A detailed, structured neurological and neuropsychiatric assessment, both pre-and post-operatively, is therefore needed to document the true incidence of this complication. There is also the need for public education, especially for those with valvular disease, in order to encourage changes in attitude and behaviour towards continued follow-up care and valve surgery, both first and `redo'. (AU)