D. J. J. Muckart

American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definitions of the systemic inflammatory response syndrome and allied disorders in relation to critically injured patients

OBJECTIVES To determine the frequency of the proposed definitions for the systemic inflammatory response syndrome (SIRS), sepsis and septic shock, and to further define severe SIRS and sterile shock as determined at 24 hrs of admission to an intensive care unit (ICU) in critically ill trauma patients without head injury, and their relationships to mechanism of injury, Acute Physiology and Chronic Health Evaluation (APACHE) II score, risk of death, Injury Severity Score (ISS), number of organ failures, and mortality rate. DESIGN Prospective, inception cohort analysis. SETTING Sixteen-bed surgical ICU in a teaching hospital. PATIENTS Four hundred fifty critically injured patients without associated head trauma. Penetrating trauma accounted for 70% (gunshot 202; stab 113) and nonpenetrating trauma for 30% (motor vehicle collision 103; blunt 32) of admissions. Three hundred ninety-four (88%) patients underwent surgical procedures. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Infective and noninfective insults were distinguished by the need for therapeutic or prophylactic antibiotics, respectively, based on an established antibiotic policy. Three hundred ninety-five (87.8%) patients fulfilled a definition of the SIRS criteria. The frequency of the definitive categories was SIRS 21.8%, sepsis 14.4%, severe SIRS 8.4%, severe sepsis 13.6%, sterile shock 9.3%, and septic shock 20.2%. Patients with penetrating trauma had a significantly higher frequency of sepsis, severe sepsis, and septic shock (p < .01). The APACHE II score, risk of death, and number of organ failures increased significantly in both infective and noninfective groups with increasing severity of the inflammatory response. Sterile shock was associated with a significantly higher APACHE II score (p < .02), risk of death (p < .01), and number of organ failures (p = .03) compared with septic shock. Only sterile shock was associated with a significantly higher ISS (p < .01). Organ system failure was significantly (p < .001) higher in nonsurvivors compared with survivors in all categories. The only significant (p < .001) difference in mortality rate was found between patients in shock and all other categories. CONCLUSIONS The current definitions of SIRS, sepsis, and related disorders in critically injured patients without head trauma show a significant association with physiologic deterioration and increasing organ dysfunction. The only significant association with mortality, however, is the presence of shock. The definitions require refinement, with the possible inclusion of more objective gradations of organ system failure, if they are to be used for stratifying severity of illness in seriously injured patients.

Intensive care unit morbidity and mortality from eclampsia: an evaluation of the Acute Physiology and Chronic Health Evaluation II score and the Glasgow Coma Scale score.

Objective: To determine the maternal morbidity and mortality in patients with eclampsia admitted to an intensive care unit (ICU), and to establish the efficacy of the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the organ system failure score as defined by Knaus, and the Glasgow Coma Scale (GCS) score in predicting outcome. Design: Retrospective analysis of a 3.5‐yr period. Setting: Surgical ICU in a university hospital. Patients: A total of 105 patients who were admitted with a diagnosis of eclampsia were studied. Interventions: None. Measurements and Main Results: The data captured included the reason for admission, maternal age, gestational age, parity, number of seizures, duration of ICU stay, anticonvulsant therapy, drug therapy, GCS score, APACHE II score, and the occurrence of organ failure. Of the 126 patients with eclampsia who were admitted to the ICU, records of 105 patients (83%) were found. The overall mortality was 10.5% (n = 11). The mean age, gestation, parity, number of preadmission seizures, and duration of stay were similar in survivors and nonsurvivors. Although the APACHE II score was significantly higher in nonsurvivors, multiple logistic regression analysis suggested that the goodness‐of‐fit scores for GCS and APACHE II were similar (38.29 vs. 38.01). The GCS scores of survivors were significantly higher than those of nonsurvivors (10.61 vs. 5.0; p < .001). Respiratory failure was the most common organ failure in both groups. The mean number of organ failures was higher in nonsurvivors compared with survivors (2.9 vs. 1.3; p < .001). An occurrence of more than two organ failures that persisted for >48 hrs was invariably associated with a fatal outcome. Anticonvulsant therapy consisted of magnesium sulfate or phenytoin and a midazolam infusion. Only one patient (0.9%) had a seizure, and this occurred en route to the ICU. No seizures occurred after admission to the ICU. Conclusions: The organ system failure score and the GCS score are good predictors of outcome in eclampsia. Apart from the GCS score, other variables in the APACHE II score are not valuable for outcome prediction. The low GCS score in nonsurvivors suggests that closer attention to the neurologic management may be beneficial. A prospective study is indicated to validate these findings.

Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU

ObjectiveTo determine a) if clinical examination can accurately predict radiological change and b) if routine chest radiography is efficacious.DesignAll mechanically ventilated patients admitted to the Surgical Intensive Care Unit over a 4-week period were entrolled into the study. A physical examination was undertaken by two clinicians to predict significant (radiographic features which alter management) and insignificant (radiographic features which do not alter management) changes. The radiographs were then reviewed by a radiologist who noted any changes from previous radiographs. The clinical findings were then correlated with the radiographical findings.SettingThe study was conducted in a 16-bedded Surgical Intensive Care Unit which admits approximately 800 patients per year. The majority of these patients require mechanical ventilation.Patients and participantsAll patients who required mechanical ventilation were included. Thirty-four patients were studied. The patients were young adults admitted primarily following trauma with a low incidence of pre-existing disease.InterventionsThere were no interventions in this study.Measurements and resultsOne hundred sixty-four radiographs were evaluated. Both examiners were efficient in predicting significant changes (sensitivity of 93 and 97%), but less efficient at predicting insignificant changes (sensitivity of 74 and 70%). Two significant radiographical changes were missed on clinical examination: one catheter malposition and one pneumothorax, representing a yield from radiography of 1%. A 52% reduction in the number of radiographs would have resulted if the need for radiography had been determined by clinical examination.ConclusionsClinical examination can effectively predict the need for radiography. Routine chest radiography is, therefore, not indicated for ventilated patients in our Surgical Intensive Care Unit.

Undetected injuries: A preventable cause of increased morbidity and mortality

A prospective audit of trauma patients managed at the discretion of six different general surgical units was performed over a 6-month period. Eighteen patients were identified in whom diagnostic delay or injuries undetected at operation contributed to increased morbidity and mortality. Failure to perform investigations as indicated by the nature of the trauma was the main reason for delay in diagnosis in seven patients. Incomplete exploration at laparotomy resulted in seven undetected injuries, while unexplored retroperitoneal hematomas accounted for the remaining four. Fourteen patients (78%) required management in the intensive care unit. Eight patients died (44%) as a result of ongoing sepsis and multiple organ failure. Seven of the deaths occurred in patients in whom surgical treatment was inadequate. Delays in diagnosis and undetected injuries, although uncommon, are a readily preventable cause of phase 3 trauma deaths. Strict adherence to standard surgical protocols as employed in dedicated trauma care centers does much to reduce unnecessary morbidity and mortality.

Obstetric and Gynaecological Patients in an Intensive Care Unit: A 1 Year Review

Management of the critically ill patient forms a significant proportion of obstetric and gynaecological (O & G) practice. There have however, been very few reports on the management of such patients in intensive care units (ICU). We review all O & G patients admitted to the surgical ICU at King Edward VIII Hospital, Durban, South Africa, and make recommendations regarding management of such patients. The medical records of all O & G patients admitted to the surgical ICU between the period January–December 1992 were analysed. Of all admissions to the ICU 13.6% (n = 122) were O & G patients. Eclampsia was the most common diagnosis accounting for 66% of all obstetric admissions. Of all eclamptics in the study period 24% were admitted to the ICU. The overall maternal mortality was 21%. O & G patients form a major workload of surgical ICUs and the majority of these patients are women with eclampsia. Management of such patients requires an understanding of the physiological changes of normal and abnormal pregnancies. Therefore, all large obstetrical units in developing countries should establish their own ICU in order that patient care, health personnel training and continuing health care education may be improved.

Guideline for the assessment of trauma centres for South Africa.

INTRODUCTION Trauma is a well-known leading cause of unnatural death and disability in South Africa. Internationally the trend is moving toward systematised care. AIM To revise the Trauma Centre Criteria of the Trauma Society of South Africa and align these with the terminology and modern scope of emergency care practice, using best-care principles as a prelude to the development of trauma systems in South Africa. METHODOLOGY Revision of existing documents of the Trauma Society of South Africa, the Emergency Medicine Society of South Africa and the Critical Care Society of Southern Africa, where these are relevant to the care of trauma. The committee attempted to harmonise these criteria with the goals of the World Health Organization essential trauma care guidelines for trauma centres and trauma systems. Wide expert consultation was undertaken to refine the criteria before final compilation. RESULTS AND RECOMMENDATIONS Four levels of trauma care facility are outlined, with the criteria focusing on the trauma-specific requirements of the facilities and their place in the greater trauma system. Accreditation of hospitals according to the criteria will allow for appropriate transfer and designation of patient destination for trauma patients and will improve the quality of care provided. The criteria address structural, process and human resource requirements and medical aspects for the accreditation of various level of trauma centre. CONCLUSION There is a great opportunity to apply best practice criteria to improve the care of trauma in South Africa and improve patient outcome.

Selective Conservatism in Trauma Management: A South African Contribution

Trauma in South Africa has been termed the malignant epidemic [1]. This heritage was the result of a violent colonial legacy [2] which spawned the apartheid system of injustice and the struggle against it [3,4] The Apartheid regime created overcrowding, unemployment, social stagnation, and the disruption of normal family life. These were the catalysts for the incredible amount of criminal and interpersonal conflict in South Africa over the last 50 years. African townships such as Soweto in Johannesburg and Umlazi in Durban were crime-ridden ghettoes where the apartheid police were more interested in fueling the ‘‘black on black’’ violence rather than trying to curb it. Baragwanath (Chris HaniBaragwanath) and King Edward the VIII Hospital in Durban were the ‘‘trauma care epicenters’’ on the fringes of these huge urban conurbations. Both were designated black hospitals and both were underfunded and dilapidated. Even the architecture was similar, with prefabricated, poorly ventilated structures serving as wards and clinics in both institutions. Trauma volumes consisted of between 10 and 20 laparotomies on weekend nights at the height of political unrest. This led to vast individual experience in several areas of trauma typified by Demetriades experience with 70 penetrating cardiac injuries [5]. In this setting of limited resources and an overwhelming volume of trauma, selective conservatism as a surgical philosophy took root and has profoundly influenced the way the world manages trauma. We detail and illustrate the evolution of this approach and its continued application. Selective conservatism is not a new concept. By necessity in the pre-anaesthetic era it was practiced for centuries with few survivors [6]. It was called into question only in the late 19th century and early 20 century when the mass casualties of modern warfare and advances in surgical and anaesthetic techniques swung the pendulum to an operative approach. This dominated surgical practice until the 1960s 5 when Shaftan [7,8] reintroduced the concept and described the successful nonoperative management of penetrating abdominal wounds. Both well-funded and resource-poor centers, some dealing with high volumes of blunt and penetrating trauma, now advocate this policy [9–14]. What does selective conservatism mean? It has more facets than simply not operating on selected individuals. The primary elements are clinical observation and re-evaluation. The first decision point is whether to intervene or continue observation and investigation. This decision is tempered by the knowledge that an intervention, either diagnostic or therapeutic, may do more harm than good. Therefore, the question must be: Is an intervention truly necessary? If the answer is yes then we need to decide what intervention is appropriate and whether a simple option would suffice instead of a complex operation. We ask these questions on a daily basis and they remain the key elements of this approach. This has generated observational studies, retrospective audits, prospective audits, and comparative studies. We present some of these to illustrate and substantiate the value of this approach in different anatomical regions and how it has developed with emerging technology. Until the mid-1980s these studies were based almost exclusively on injuries inflicted by stab wounds. Since then there has been a significant change in the nature of penetrating trauma in South Africa as typified by the reports from clinical and forensic audits [15, 17–17]. From 1983 to 1992 [15] 2500 penetrating torso injuries were treated annually. Over that decade stab wounds declined by 30% but firearm wounds increased by 873% with a mortality rate of 1.6% for stabs and 12.5% for firearms. This has prompted us to review our approach to these problems to see if the principles of selective conservatism need to be modified when applied to firearm injuries. Penetrating Neck Trauma The high concentration and intimate relationship of vital structures in the neck meant that most surgeons felt that exploration was mandatory for any injury that penetrated the platysma muscle. The natural history and the results of a selective policy were documented at Baragwanath [18]. In 1980 [19] over a six-month period 108 patients admitted to King Edward the VIII were prospectively evaluated. Exploration was undertaken only for hard clinical or radiologic signs of vascular or aerodigestive injury. Only 26 were explored of whom two died. In the conservative group one died from an associated thoracic injury. This concept of nonoperative management was again analyzed in a cohort of Correspondence to: S. R. Thomson, ChM, FRCS (Ed and Eng), e-mail: Thomson@ukzn.ac.za World J. Surg. 29, 962–965 (2005) DOI: 10.1007/s00268-005-0131-9

The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit

PURPOSE This study aimed to identify the incidence and outcomes of patients with trauma related acute kidney injury (AKI), as defined by RIFLE criteria, at a single level I trauma centre and trauma ICU. METHODS We performed a retrospective observational study of 666 patients admitted to a trauma ICU from a level I trauma unit from March 2008 to March 2011. We conducted multivariable logistic regression to identify independent predictors for AKI and mortality. RESULTS The overall incidence of AKI was 15% (n=102). Median injury severity score (ISS) was 25 (inter quartile range [IQR] 16-34) and mean age was 39 (SD 16.3) in the AKI group. Thirteen patients (13%) were referred with rhabdomyolysis associated renal Failure. Overall mortality in the AKI group was 57% (n=58) but was significantly lower in the rhabdomyolysis Failure group (23% versus 64%; p=0.012). AKI was independently associated with older age, base excess (BE)<-12 (odd ratio [OR] 22.9, 95% confidence interval [CI] 1.89-276.16), IV contrast administration (OR 2.7 95% CI 1.39-5.11) and blunt trauma (OR 2.2 95% CI 1.04-4.71). AKI was an independent predictor of mortality (OR 8.5, 95% CI 4.51-15.95). Thirty-nine (38%) patients required renal replacement therapy. CONCLUSIONS AKI in critically ill trauma patients is an independent risk factor for mortality and is independently associated with increasing age and low BE. Renal replacement therapy utilisation is high in this group and represents a significant health care cost burden.

The spectrum of diaphragmatic injury in a busy metropolitan surgical service.

INTRODUCTION The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component. METHODOLOGY A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study. RESULTS A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy. CONCLUSION If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.

An Assessment of the Hospital Disease Burden and the Facilities for the In-hospital Care of Trauma in KwaZulu-Natal, South Africa

BackgroundTrauma is a significant cause of morbidity and mortality in South Africa. The present study was designed to review the hospital trauma disease burden in light of the facilities available for the care of the injured in KwaZulu-Natal (KZN), South Africa’s most populous province.The primary outcomes were the annual hospital burden of trauma in KZN, determined through data extrapolation, and evaluation of the data in light of available hospital facilities within the province of KZN, a developing province. The data were obtained through review of the trauma load in relation to all emergency cases at all levels of hospitals.MethodsHospital administrators in KZN were requested to submit trauma caseloads for the months of March and September 2010. Caseloads were reviewed to determine the trauma load for the province per category using two extrapolation methods to determine the predicted range of annual incidence of trauma, intentional versus non-intentional trauma ratios and population-related incidence of trauma. The results were GIS mapped to demonstrate variations across districts. Hospital data were obtained from assessments of structure, process, and personnel undertaken prior to a major sporting event. These were compared to the ideal facilities required for accreditation of trauma care facilities of the Trauma Society of South Africa and other established documents.ResultsData were obtained from 36 of the 47 public hospitals in KZN that manage acute emergency cases. The predicted annual trauma incidence in KZN ranges from 124,000 to 125,000, or 12.9 per 1,000 population. This would imply a national public hospital trauma load on the order of at least 750,000 cases per year. Most hospitals are required to treat trauma; however, within KZN many hospitals do not have adequate personnel, medical equipment, or structural integrity to be formally accredited as trauma care facilities in terms of existing criteria.ConclusionsThere is a significant trauma load that consumes vital emergency center resources. Most hospitals will need extensive upgrading to provide appropriate care for trauma. An inclusive trauma system needs to be formalized and funded, especially in light of the planned National Health Insurance for South Africa