Current practice in transferring critically ill patients among hospitals in the west of Scotland.

OBJECTIVE--To identify the requirements of an interhospital transfer service for critically ill patients. DESIGN--Retrospective survey of the current functions of a specialist interhospital transfer team from data collected at the time of transfer and from records of intensive care unit. SETTING--Mobile intensive care unit based at a tertiary referral centre, which serves the west of Scotland. PATIENTS--All critically ill patients (378) transferred between hospitals by the unit from 1986 to 1988. RESULTS--365 Patients were transferred by road and 13 by air. There was a wide variation in age (range 6 weeks to 87 years), diagnosis, reason for transfer, support required, and distance travelled. Most patients (232) were transferred for respiratory or cardiovascular support; 100 were trauma cases. 300 Patients (79%) were mechanically ventilated during transfer. No patient died in transit, although the eventual mortality was 28% (105 patients). Mortality was significantly higher in patients transferred from hospitals with intensive care units than from those without (38% (125 patients) v 23% (253); p less than 0.005). IMPLICATIONS--Safe interhospital transfer of critically ill patients is feasible; the high eventual mortality in some patient groups emphasises the need for accurate prediction of outcome if inappropriate transfer is to be avoided. The findings may help in organising secondary transfer services in future.     

Effects of ambulance transport in critically ill patients.

Two groups of critically ill patients were transferred by ambulance from other hospitals to a central intensive therapy unit. The effect of transport was reviewed retrospectively in 46 patients and prospectively in 20 patients. Of the 46 patients reviewed retrospectively six became hypotensive, six became hypertensive, and seven developed delayed hypotension. One patient developed fits and six out of 13 patients had a rise in arterial PCO-2 of 1-6-4-1 kPa (12-31 mm Hg). Of the 20 patients reviewed prospectively, one patient became hypertensive due to overtransfusion, one had a fit, but none became hypotensive. Three out of four cases of delayed hypotension were related to starting intermittent positive pressure ventilation. Arterial PCO-2 fell in one patient and arterial PCO-2 rose in two, each change being related to changed oxygen therapy or narcotics. There were no changes in other cardiovascular or respiratory indices, body temperature, or urine production. Earlier transfer, resuscitation before transfer, continuing medical care during the journey, and hence a slower smoother journey seemed to be important factors in the management of these patients. Our findings, may have important implications in the future regional organization of the care of critically ill patients.     

Validation of a prognostic score in critically ill patients undergoing transport.

Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE II) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care. No patient died during transport. Twenty two patients died subsequently in hospital and 28 survived to return home. The mean score for the non-survivors before resuscitation was 21.7 and for the survivors 12.2 (p less than 0.0005). Among the non-survivors there was a significant fall in score with resuscitation but this did not alter their subsequent outcome. Neither group deteriorated during transport. The sickness score is a powerful method for determining prognosis, and employed longitudinally it may be useful in the assessment of treatment. It has important implications for the administration and organisation of regional intensive care services.     

Hematologic and oncologic complications in the critically ill child

Admission of a patient to an intensive care unit for management of direct consequences of a hematologic or oncologic disease is occasionally necessary. Such problems included exchange transfusion, sepsis, compression of vital structures by malignant tumor, metabolic derangements, leukostasis, post-operative care, major sickling episodes in vital organs, and disseminated coagulopathy. More often, however, hematologic complications arise in the child critically ill from other causes, such as trauma or infections. The first two sections of this review address blood transfusion and hemostasis, topics likely to have wide application in the care of critically ill children. The last portion discusses problems unique to patients with sickling or malignant disease.     

An economical mobile intensive care unit.

A mobile intensive care unit is an important extension of a regional intensive treatment service. The treatment and monitoring of critically ill patients can be maintained during transfer for specialist investigation or treatment. Such units can be brought into service with low construction and running costs.     

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death

Purpose

Critically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.

Methods

A year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.

Results

The study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.

Conclusions

The study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.     

Respite care on a children's ward.

In March 1984 a short term respite care facility for handicapped children was opened in a children''s ward catering primarily for acute medical and surgical problems. The facility was based on a four bedded room designed so that if beds became short in the main ward it could revert immediately to the care of acutely sick children. Three nurses were appointed specifically to staff the facility, the nursing budget for the rest of the ward being reduced proportionately. Conversions were funded by charities and some of the conversion work done by volunteers. The main users were totally dependent children aged under 5 with severe mental and physical handicaps. Parents found the service invaluable, and in addition to planned admissions it was usually possible to accept a child at short notice--for example, when some domestic crisis occurred. Only very rarely was admission impossible because of the needs of acutely ill children. A short term respite care facility not only helps parents cope and may provide beneficial experience for a handicapped child but is also a useful training ground for medical students and junior staff.     

Care Seeking for Neonatal Illness in Low- and Middle-Income Countries: A Systematic Review

Background

Despite recent achievements to reduce child mortality, neonatal deaths continue to remain high, accounting for 41% of all deaths in children under five years of age worldwide, of which over 90% occur in low- and middle-income countries (LMICs). Infections are a leading cause of death and limitations in care seeking for ill neonates contribute to high mortality rates. As estimates for care-seeking behaviors in LMICs have not been studied, this review describes care seeking for neonatal illnesses in LMICs, with particular attention to type of care sought.

Methods and Findings

We conducted a systematic literature review of studies that reported the proportion of caregivers that sought care for ill or suspected ill neonates in LMICs. The initial search yielded 784 studies, of which 22 studies described relevant data from community household surveys, facility-based surveys, and intervention trials. The majority of studies were from South Asia (n = 17/22), set in rural areas (n = 17/22), and published within the last 4 years (n = 18/22). Of the 9,098 neonates who were ill or suspected to be ill, 4,320 caregivers sought some type of care, including care from a health facility (n = 370) or provider (n = 1,813). Care seeking ranged between 10% and 100% among caregivers with a median of 59%. Care seeking from a health care provider yielded a similar range and median, while care seeking at a health care facility ranged between 1% and 100%, with a median of 20%. Care-seeking estimates were limited by the few studies conducted in urban settings and regions other than South Asia. There was a lack of consistency regarding illness, care-seeking, and care provider definitions.

Conclusions

There is a paucity of data regarding newborn care-seeking behaviors; in South Asia, care seeking is low for newborn illness, especially in terms of care sought from health care facilities and medically trained providers. There is a need for representative data to describe care-seeking patterns in different geographic regions and better understand mechanisms to enhance care seeking during this vulnerable time period. Please see later in the article for the Editors'' Summary     

Management of the pediatric patient after cardiac surgery

The medical management of the child with congenital cardiac disease prior to and following cardiac surgery has made a substantial contribution to the improved morbidity and mortality attributed to surgical advances. This paper provides a framework for understanding the problems that arise in the perioperative period and a systematic approach, by organ system, to monitoring and management of these problems. The discussion is intended to be of general application, focusing on initial stabilization following surgery and the cardiorespiratory, renal, metabolic, hematologic, and neurologic alterations that result from surgery with cardiopulmonary bypass. An approach for the management of the low output state is also provided. Little attempt has been made to focus on problems unique to a specific type of cardiac disease or certain operative approaches. Rather, it is the contention that an understanding of general principles and an appreciation of the common problems will provide adequate preparation for those responsible for the care of the child.     

Angiopoietin-1, Angiopoietin-2 and Bicarbonate as Diagnostic Biomarkers in Children with Severe Sepsis

Severe pediatric sepsis continues to be associated with high mortality rates in children. Thus, an important area of biomedical research is to identify biomarkers that can classify sepsis severity and outcomes. The complex and heterogeneous nature of sepsis makes the prospect of the classification of sepsis severity using a single biomarker less likely. Instead, we employ machine learning techniques to validate the use of a multiple biomarkers scoring system to determine the severity of sepsis in critically ill children. The study was based on clinical data and plasma samples provided by a tertiary care center''s Pediatric Intensive Care Unit (PICU) from a group of 45 patients with varying sepsis severity at the time of admission. Canonical Correlation Analysis with the Forward Selection and Random Forests methods identified a particular set of biomarkers that included Angiopoietin-1 (Ang-1), Angiopoietin-2 (Ang-2), and Bicarbonate (HCO) as having the strongest correlations with sepsis severity. The robustness and effectiveness of these biomarkers for classifying sepsis severity were validated by constructing a linear Support Vector Machine diagnostic classifier. We also show that the concentrations of Ang-1, Ang-2, and HCO enable predictions of the time dependence of sepsis severity in children.     

Does hemodynamic monitoring complement conventional methods of assessment in the critically ill cardiac patient?

Conventional clinical methods give qualitative information about left ventricular function in the critically ill patient. However, the information gathered from the physical examination and noninvasive methods is subject to important pitfalls with respect to both its nonspecificity and interobserver variability. The advent of hemodynamic monitoring has highlighted these difficulties and provided more quantitative information that is relevant in both diagnosis and treatment of the critically ill patient.     

危重症患者预后的危险因素及相关指标的预后预测价值分析

目的:探讨危重症患者预后的危险因素,并分析相关指标对患者预后的预测价值。方法:对2016年4月至2018年4月上海交通大学附属第六人民医院救治的5585例ICU危重症患者病例进行回顾性分析,收集患者一般资料、初始乳酸水平、24 h乳酸水平、24 h乳酸清除率以及APACHEII评分等,采用多因素logistic回归分析危重症患者预后的影响因素,ROC曲线评估多项指标预测患者预后的价值。结果:共纳入1465例危重症患者,多因素logistic回归分析显示,住ICU平均时间长、APACHEII评分高、初始乳酸水平大于4 mmol/L、24 h乳酸清除率低、术后肾功能异常是危重症患者住院期间死亡的危险因素(P0.05),24 h乳酸清除率、APACHEII评分及初始乳酸水平三者联合评估预测患者住院死亡率的ROC曲线下面积(ROC-AUC)为0.900,高于单独检测。结论:住ICU时间、APACHEII评分、初始乳酸水平、24 h乳酸清除率、术后肾功能是危重症患者住院期间死亡的影响因素,初始乳酸水平、24 h乳酸清除率和APACHEII评分联合使用可以更好地预测危重症患者的短期预后。     

Invasive fungal infections in critically ill patients: different therapeutic options and a uniform strategy

The high morbidity, mortality, and healthcare costs associated with the invasive fungal infections, especially in the critical care setting, is of importance since the prophylactic, empiric, and pre-emptive therapy interventions, based on early identification of risk factors, is of common occurrence. In the last years alone there have been important developments in antifungal pharmacotherapy. Evidence-based studies using new antifungal agents are now emerging as important players in the pharmacotherapy of invasive fungal infections in seriously ill and difficult patients. However, data on critically ill patients are more limited and usually recovered from general studies. This study shows the benefits obtained by the new antifungal agents on different clinical situations in critical care units. The increasing number of non-C. albicans species and the high mortality rates in these settings suggest that the application of early de-escalation therapy in critically ill patients with fungal infection should be mandatory. The possibility of using antifungal combination therapy in these types of patients should be considered.     

Serial measurements of whole blood nitrite in an intensive care setting

Nitrite plays an eminent role in cardiovascular physiology and pathology, mediating hypoxic vasodilation, reducing ischemia–reperfusion injury, and regulating cardiac energetics and function. The role of circulating nitrite in critically ill patients has not been examined so far. To investigate whether whole blood nitrite can be determined reproducibly in an intensive care setting, 30 patients from a cardiology intensive care unit were enrolled in this study, no matter what the underlying disease. Blood was drawn from an arterial catheter and whole blood nitrite was determined, using a tri-iodide/ozone-based chemiluminescence assay after incubation with a ferricyanide-containing stabilization solution. Whole blood nitrite levels ranged from 35 to 1193 nmol/L (mean ± SEM: 220 ± 20 nmol/L). Myocardial infarction was associated with lower whole blood nitrite levels (200 ± 53 nmol/L for elevated serum CK MB levels vs 432 ± 95 nmol/L in the normal CK MB range, p = 0.039). Neither impaired kidney function nor an inflammatory state was associated with higher or lower whole blood nitrite levels. In conclusion, whole blood nitrite can be measured easily and reproducibly in critically ill patients, regardless of renal function and inflammation. The origin of decreased nitrite levels in myocardial infarction is currently unclear and needs to be further elucidated.     

Extravascular lung water measurements and hemodynamic monitoring in the critically ill: bedside alternatives to the pulmonary artery catheter

The recently completed Fluid and Catheter Treatment Trial conducted by the National Institutes of Health ARDSNetwork casts doubt on the value of routine pulmonary artery catheterization for hemodynamic management of the critically ill. Several alternatives are available, and, in this review, we evaluate the theoretical, validation, and empirical databases for two of these: transpulmonary thermodilution measurements (yielding estimates of cardiac output, intrathoracic blood volume, and extravascular lung water) that do not require a pulmonary artery catheter, and hemodynamic measurements (including estimates of cardiac output and ejection time, a variable sensitive to intravascular volume) obtained by esophageal Doppler analysis of blood flow through the descending aorta. We conclude that both deserve serious consideration as a means of acquiring useful hemodynamic data for managing shock and fluid resuscitation in the critically ill, especially in those with acute lung injury and pulmonary edema, but that additional study, including carefully performed, prospective clinical trials demonstrating outcome benefit, is needed.     

Management of septic shock.

There have been important advances in the resuscitation of patients in septic shock in recent years. Survival can be improved by earlier recognition and therefore eradication of the sepsis combined with logical supportive measures. As with any acutely ill patient consultation with intensive care unit staff may be useful. Consultation with the intensive care unit does not necessarily imply the need for admission and mechanical ventilation; helpful advice may be forthcoming. Equally, referral to the intensive care unit does not mean an admission of failure but merely a recognition that additional skills and technical facilities are necessary for the patient''s survival.     

Neonatal resuscitation in Canadian hospitals.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members'' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.     

Optimal input design: case study of the metabolic process

An optimal input of nutrients into the metabolic process of the individual subject so as to effect desired therapeutic results is particularly important for the critically ill. A patient-related, individualized nutrients optimization procedure is proposed here. The procedure is applicable to any time-invariant and deterministic metabolic model that is bound by one or more quantitative limiting criteria. As a case in hand, the procedure is used to optimize the individual metabolic needs of critically ill patients. The results indicate that, given a proper metabolic model, the patient may be treated on an individual appropriateness basis rather than on the traditional statistical intuitive approach.     

Childhood malignancies and decision making.

Failure to obtain "adequate" medical care for a child constitutes child neglect, which may be used as the basis for prosecution of parents, removal of the child from the home, or court-ordered medical treatment. "Adequate" care is usually construed as that which is given by a licensed physician, but, in case of dispute, courts almost never engage in choosing one medical approach over another. The principle that parents may not refuse medical care, however, is made very difficult when children have malignancies--the long-term nature of the treatment means that, if the child is left at home, court order or not, the parents may flee with their child. Removing the child from the home, however, adds that trauma to the ill child's burdens. Questions should be asked before making a request to a court to order a therapy which will prolong but not save a child's life if the parents would prefer to spare their child the side effects. Parents, however, may always refuse to permit their child to participate in research studies, no matter how promising. Adolescents are increasingly believed to be capable of medical decision making; most courts, however, would not allow an adolescent to refuse life-saving treatment.