B. L. Taylor

Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: Summary report of the European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster

PurposeTo provide recommendations and standard operating procedures for intensive care units and hospital preparedness for an influenza pandemic.MethodsBased on a literature review and expert opinion, a Delphi process was used to define the essential topics.ResultsKey recommendations include: Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas. Establish a management system with control groups at facility, local, regional and/or national levels to exercise authority over resources. Establish a system of communication, coordination and collaboration between the ICU and key interface departments. A plan to access, coordinate and increase labor resources is required with a central inventory of all clinical and non-clinical staff. Delegate duties not within the usual scope of workers’ practice. Ensure that adequate essential medical equipment, pharmaceuticals and supplies are available. Protect patients and staff with infection control practices and supporting occupational health policies. Maintain staff confidence with reassurance plans for legal protection and assistance. Have objective, ethical, transparent triage criteria that are applied equitably and publically disclosed. ICU triage of patients should be based on the likelihood for patients to benefit most or a ‘first come, first served’ basis. Develop protocols for safe performance of high-risk procedures. Train and educate staff.ConclusionsMortality, although inevitable during a severe influenza outbreak or disaster, can be reduced by adequate preparation.

Modelling the impact of an influenza pandemic on critical care services in England.

The UK Influenza Pandemic Contingency Plan does not consider the impact of a pandemic on critical care services. We modelled the demand for critical care beds in England with software developed by the Centers for Disease Control (Flusurge 1.0), using a range of attack rates and pandemic durations. Using inputs that have been employed in UK Department of Health scenarios (25% attack rate and 8‐week pandemic duration) resulted in a demand for ventilatory support that exceeded 200% of present capacity. Demand remained unsustainably high even when more favourable scenarios were considered. Current critical care bed capacity in England would be unable to cope with the increased demand provided by an influenza pandemic. Appropriate contingency planning is essential.

Modelling the impact of an influenza A/H1N1 pandemic on critical care demand from early pathogenicity data: the case for sentinel reporting

Projected critical care demand for pandemic influenza H1N1 in England was estimated in this study. The effect of varying hospital admission rates under statistical uncertainty was examined. Early in a pandemic, uncertainty in epidemiological parameters leads to a wide range of credible scenarios, with projected demand ranging from insignificant to overwhelming. However, even small changes to input assumptions make the major incident scenario increasingly likely. Before any cases are admitted to hospital, 95% confidence limit on admission rates led to a range in predicted peak critical care bed occupancy of between 0% and 37% of total critical care bed capacity, half of these cases requiring ventilatory support. For hospital admission rates above 0.25%, critical care bed availability would be exceeded. Further, only 10% of critical care beds in England are in specialist paediatric units, but best estimates suggest that 30% of patients requiring critical care will be children. Paediatric intensive care facilities are likely to be quickly exhausted and suggest that older children should be managed in adult critical care units to allow resource optimisation. Crucially this study highlights the need for sentinel reporting and real‐time modelling to guide rational decision making.

Effect of three emergency pacing modalities on cardiac output in cardiac arrest due to ventricular asystole

Pacing is a well recognised treatment in asystolic arrest with residual p wave activity. This can be achieved by transvenous, transthoracic, or manual external (cardiac percussion) pacing techniques. We report a case of ventricular asystole in which all three pacing modalities were applied, and demonstrate their relative effectiveness with invasive haemodynamic monitoring data. Stroke volumes were comparable with all three methods. Manual external pacing is an effective holding measure when cardiac output is compromised due to bradycardia or asystole with residual p wave activity before more definitive pacing techniques are instituted.

The impact of low-risk intensive care unit admissions on mortality probabilities by SAPS II, APACHE II and APACHE III

A large proportion of intensive care unit patients are low‐risk admissions. Mortality probabilities generated by predictive systems may not accurately reflect the mortality experienced by subpopulations of critically ill patients. We prospectively assessed the impact of low‐risk admissions (mortality risk <u200a10%) on the mortality estimates generated by three prognostic models. We studied 1497 consecutive admissions to a general intensive care unit. The performance of the three models for subgroups and the whole population was analysed. The proportions of patients designated as low risk varied with the model and differences in model performance were most pronounced for these patients. The APACHE II mortality ratios (1.32 vs. 1.19) did not differ for low‐ and higher risk patients, but mortality ratios generated by APACHE III (2.38 vs. 1.23) and SAPS II (2.19 vs. 1.16) were nearly two‐fold greater. Calibration for higher risk patients was similar for all three models but the APACHE III system calibrated worse than the other models for low‐risk patients. This may have contributed to the poorer overall calibration of the APACHE III system (Hosmer–Lemeshow C‐test: APACHE III χ2u2003=u2003329; APACHE II χ2u2003=u200342; SAPS II χ2u2003=u200362). Imperfect characterisation of the large proportion of low‐risk intensive care unit admissions may contribute to the deterioration of the models predictive accuracies for the intensive care population as a whole.

Chapter 3. Coordination and collaboration with interface units. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster.

PurposeTo provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on enhancing coordination and collaboration between the ICU and other key stakeholders.MethodsBased on a literature review and expert opinion, a Delphi process was used to define the essential topics including coordination and collaboration.ResultsKey recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resource use and communications; (2) develop a system of communication, coordination and collaboration between the ICU and key interface departments within the hospital; (3) identify key functions or processes requiring coordination and collaboration, the most important of these being manpower and resources utilization (surge capacity) and re-allocation of personnel, equipment and physical space; (4) develop processes to allow smooth inter-departmental patient transfers; (5) creating systems and guidelines is not sufficient, it is important to: (a) identify the roles and responsibilities of key individuals necessary for the implementation of the guidelines; (b) ensure that these individuals are adequately trained and prepared to perform their roles; (c) ensure adequate equipment to allow key coordination and collaboration activities; (d) ensure an adequate physical environment to allow staff to properly implement guidelines; (6) trigger events for determining a crisis should be defined.ConclusionsJudicious planning and adoption of protocols for coordination and collaboration with interface units are necessary to optimize outcomes during a pandemic.

Chapter 3. Coordination and collaboration with interface units

PurposeTo provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on enhancing coordination and collaboration between the ICU and other key stakeholders.MethodsBased on a literature review and expert opinion, a Delphi process was used to define the essential topics including coordination and collaboration.ResultsKey recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resource use and communications; (2) develop a system of communication, coordination and collaboration between the ICU and key interface departments within the hospital; (3) identify key functions or processes requiring coordination and collaboration, the most important of these being manpower and resources utilization (surge capacity) and re-allocation of personnel, equipment and physical space; (4) develop processes to allow smooth inter-departmental patient transfers; (5) creating systems and guidelines is not sufficient, it is important to: (a) identify the roles and responsibilities of key individuals necessary for the implementation of the guidelines; (b) ensure that these individuals are adequately trained and prepared to perform their roles; (c) ensure adequate equipment to allow key coordination and collaboration activities; (d) ensure an adequate physical environment to allow staff to properly implement guidelines; (6) trigger events for determining a crisis should be defined.ConclusionsJudicious planning and adoption of protocols for coordination and collaboration with interface units are necessary to optimize outcomes during a pandemic.

Continuous ascitic recirculation in severe ovarian hyperstimulation syndrome

Massive ascites, hydrothorax, acute renal failure and thromboembolism are clinical manifestations of severe ovarian hyperstimulation syndrome (OHSS) which may complicate the induction of ovulation with exogenous gonadotrophins. We report a case of severe OHSS with ascites formation in excess of five litres per day. Massive ascites and bilateral pleural effusions resulted in respiratory failure. Continuous ascitic recirculation (AR) was commenced after repeated paracentesis and IV fluid therapy failed to improve the patients condition. The procedure was undertaken for a total of 15 days and rapidly resulted in marked improvement of impaired respiratory function. Febrile episodes occurred on 3 occasions, but we did not observe coagulation disturbances or adverse haemodynamic effects. Continuous AR is a safe and effective treatment of complicated severe OHSS.

Chapter 6. Protection of patients and staff during a pandemic

PurposeTo provide recommendations and standard operating procedures (SOPs) for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on protection of patients and staff.MethodsBased on a literature review and expert opinion, a Delphi process was used to define the essential topics including protection of patients and staff.ResultsKey recommendations include: (1) prepare infection control and occupational health policies for clinical risks relating to potential disease transmission; (2) decrease clinical risks and provide adequate facilities through advanced planning to maximise capacity by increasing essential equipment, drugs, supplies and encouraging staff availability; (3) create robust systems to maintain staff confidence and safety by minimising non-clinical risks and maintaining or escalating essential services; (4) prepare formal reassurance plans for legal protection; (5) provide assistance to staff working outside their normal domains.ConclusionsJudicious planning and adoption of protocols for protection of patients and staff are necessary to optimise outcomes during a pandemic.

Misplacement of a mini‐tracheostomy

Morbidity associated with the insertion of a minitracheostomy (Mini-Trach 11, Portex Ltd, Hythe, Kent) has been described [l, 21. We wish to report a serious complication that has not been previously reported. An 80-year-old woman underwent surgery for the excision of a pharyngeal pouch. During attempts to pass a nasogastric tube a small laceration was made in the posterior pharyngeal wall, but the operation was otherwise uneventful. Her initial recovery was uncomplicated and she was returned to the general ward. Four hours later she developed stridor and within a further hour she had developed signs of severe upper airway obstruction which necessitated urgent tracheal intubation. At laryngoscopy an acute supraglottitis was evident, with distortion and oedema of the vocal cords. She was transferred to the intensive care unit (ICU), where sedation and mechanical ventilation was continued for 72 h, during which she received intravenous antibiotic therapy in the form of cefotaxime and metronidazole. On the fourth postoperative day direct laryngoscopy showed that the supraglottic inflammation had resolved and the vocal cords appeared normal. Sedation was discontinued and the patient’s trachea was extubated when she was awake and cooperative. After extubation, her respiratory state was initially good, but it became apparent over a few hours that she was unable to clear secretions due to a weak cough. In view of the recent pharyngeal surgery blind nasotracheal suction was contraindicated and it was therefore decided to insert a Mini-Trach to aid sputum clearance. The combination of a short, wide neck and residual tissue swelling from the original operation made identification of the surface markings of the larynx very difficult, so the assistance of an ENT surgeon was requested. Following infiltration with local anaesthetic, the anterior aspect of the trachea was exposed by blunt dissection. The cricoid cartilage was identified and the Mini-Trach inserted between the first and second tracheal rings, but the introducer had to be inserted perpendicularly because of restricted neck extension. Difficulty was encountered when the introducer abutted the posterior tracheal wall, but as the introducer was withdrawn the Mini-Trach was advanced without resistance. Air was aspirated easily suggesting correct placement. Within seconds the patient displayed signs of severe airway obstruction and pulse oximetry showed significant desaturation. Oxygenation was rapidly restored by bag/mask ventilation. Anaesthesia was induced with propofol 80 mg and direct laryngoscopy performed. This revealed that the Mini-Trach had passed up through the larynx and that the tip was positioned in the oropharynx. The Mini-Trach was removed, an orotracheal tube was inserted and mechanical ventilation re-established. Under propofol anaesthesia, the Mini-Trach route was converted to a formal tracheostomy and a size 6.5 Portex tracheostomy tube was inserted. The patient was weaned from mechanical ventilation and discharged to the ward the following day. The tracheostomy was removed 5 days later and she made an uneventful recovery. This case illustrates that the technique of ‘railroading’ a Mini-Trach cannula over its introducer may result in misdirection and misplacement and that aspiration of air through the Mini-Trach does not necessarily indicate correct placement. In our patient, irritation of the larynx by the retrograde passage of the tube appeared to produce laryngospasm and airway obstruction. If difficulty is encountered in inserting the introducer or Mini-Trach cannula then it may be prudent to perform laryngoscopy to ensure that retrograde passage has not occurred.