Fathima Paruk

Severe obstetric morbidity.

Obstetric morbidity is an important marker of the quality of obstetric care. This review explores the definition, incidence and significance of obstetric morbidity. Some topical issues related to obstetric morbidity are discussed. In addition, the importance of long-term morbidity and violence against women is highlighted.

Infection in obstetric critical care

Infections in critically ill obstetric patients are observed worldwide, although the incidence, aetiology and patient outcome vary between geographic locations. This chapter focuses on sepsis, with emphasis on the pathophysiology, outcome and specific management issues.

Evaluation of standard and modified severity of illness scores in the obstetric patient

PURPOSE To test discrimination and calibration of APACHE-II and SAPS-II risk prediction scores in a cohort of obstetric patients, and to evaluate the effect of modifying these scores for the physiological changes in pregnancy. MATERIALS AND METHODS A retrospective review of obstetric patients, 12 weeks gestation to 48 hours postpartum, admitted to the ICU for more than 24 hours. APACHE-II and SAPS-II, and versions modified for the physiological changes of pregnancy, were evaluated by receiver operating characteristic (ROC) curves and standardized mortality ratios (SMR). Multivariable analysis identified other parameters associated with mortality. RESULTS Data were obtained from 332 patients from 5 countries, with a mortality rate of 12%. Mean (± SD) APACHE-II score was 16.8 ± 6.1 and SAPS-II score 26.5 ± 15.8. Good discrimination was demonstrated with area under the ROC curves of 0.82 and 0.78 respectively, with no improvement after modification for altered maternal physiology. APACHE-II overestimated mortality, with an SMR of 0.43 (0.52 after including diagnostic weighting) compared with 0.89 for SAPS-II. Bilirubin, albumin and Glasgow Coma Scale were independently associated with mortality. CONCLUSION APACHE-II and SAPS-II are good discriminators of illness severity and may be valuable for comparing obstetric cohorts, but APACHE-II significantly over-estimates mortality.

Antibiotic prescription practices and their relationship to outcome in South Africa: Findings of the prevalence of infection in South African intensive care units (PISA) study

BACKGROUND The emergence of multidrug-resistant, extensively resistant and pan-resistant pathogens and the widespread inappropriate use of antibiotics is a global catastrophe receiving increasing attention by health care authorities. The antibiotic prescription practices in public and private intensive care units (ICUs) in South Africa are unknown. OBJECTIVE To document antibiotic prescription practices in public and private ICUs in South Africa and to determine their relationship to patient outcomes. METHODS A national database of public and private ICUs in South Africa was prospectively studied using a proportional probability sampling technique. RESULTS Two hundred and forty-eight patients were recruited. Therapeutic antibiotics were initiated in 182 (73.5%), and 54.9% received an inappropriate antibiotic initially. De-escalation was practised in 33.3% and 19.7% of the public and private sector patients, respectively. Antibiotic duration was inappropriate in most cases. An appropriate choice of antibiotic was associated with an 11% mortality, while an inappropriate choice was associated with a 27% mortality (p=0.01). The mortality associated with appropriate or inappropriate duration of antibiotics was 17.6% and 20.6%, respectively (p=0.42). CONCLUSION Inappropriate antibiotic prescription practices in ICUs in the public and private sectors in South Africa are common and are also associated with poor patient outcomes.

The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation—the approach should be individualized

PURPOSE The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support. MATERIALS AND METHODS Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation. RESULTS Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios. CONCLUSIONS Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.

The Durban World Congress Ethics Round Table Conference Report: II. Withholding or withdrawing of treatment in elderly patients admitted to the intensive care unit

INTRODUCTION Life-sustaining treatment (LST) limitation for elderly patients is highly controversial. In that context, it is useful to evaluate the attitudes to LST in the elderly among experienced intensive care unit (ICU) physicians with different backgrounds and cultures. METHODS A panel of 22 international ICU physicians from 13 countries responded to a questionnaire related to withholding (WH) and withdrawing (WD) LST in elderly patients using a semi-Likert scale. RESULTS Most experts disagree or strongly disagree (77%) that age should be used as the sole criterion for WH or WD LST, and almost all disagree (91%) that there should be a specific age for such decision making. However, the vast majority (91%) acknowledge that age should be an important consideration in conjunction with other factors. Disagreement for consideration of prioritizing the young over the old in normal ICU operations was reported in 68%, whereas in an emergency triage situation, disagreement dropped to 18%. CONCLUSIONS There is a consensus among ICU physicians that age cannot be the sole criterion on which health care decisions should be made. In that perspective, it is important to provide data showing that outcome differences between elderly and nonelderly patients are partly related to decisions to forgo LSTs.

The Durban World Congress Ethics Round Table IV: Health care professional end-of-life decision making

INTRODUCTION When terminal illness exists, it is common clinical practice worldwide to withhold (WH) or withdraw (WD) life-sustaining treatments. Systematic documentation of professional opinion and perceived practice similarities and differences may allow recommendations to be developed. MATERIALS AND METHODS Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress that took place in Durban (2013), with an interest in ethics, were approached to participate in an ethics round table. Key domains of health care professional end-of-life decision making were defined, explored by discussion, and then questions related to current practice and opinion developed and subsequently answered by round-table participants to establish the presence or absence of agreement. RESULTS Agreement was established for the desirability for early goal-of-care discussions and discussions between health care professionals to establish health care provider consensus and confirmation of the grounds for WH/WD, before holding formal WH/WD discussions with patients/surrogates. Nurse and other health care professional involvement were common in most but not all countries/regions. Principles and practical triggers for initiating discussions on WH/WD, such as multiorgan failure, predicted short-term survival, and predicted poor neurologic outcome, were identified. CONCLUSIONS There was majority agreement for many but not all statements describing health care professional end-of-life decision making.

Dosing antibiotic prophylaxis during cardiopulmonary bypass—a higher level of complexity? A structured review

In highly invasive procedures such as open heart surgery, the risk of post-operative infection is particularly high due to exposure of the surgical field to multiple foreign devices. Adequate antibiotic prophylaxis is an essential intervention to minimise post-operative morbidity and mortality. However, there is a lack of clear understanding on the adequacy of traditional prophylactic dosing regimens, which are rarely supported by data. The aim of this structured review is to describe the relevant pharmacokinetic/pharmacodynamic (PK/PD) considerations for optimal antibiotic prophylaxis for major cardiac surgery including cardiopulmonary bypass (CPB). A structured review of the relevant published literature was performed and 45 relevant studies describing antibiotic pharmacokinetics in patients receiving extracorporeal CPB as part of major cardiac surgery were identified. Some of the studies suggested marked PK alterations in the peri-operative period with increases in volume of distribution (Vd) by up to 58% and altered drug clearances of up to 20%. Mechanisms proposed as causing the PK changes included haemodilution, hypothermia, retention of the antibiotic within the extracorporeal circuit, altered physiology related to a systemic inflammatory response, and maldistribution of blood flow. Of note, some studies reported no or minimal impact of the CPB procedure on antibiotic pharmacokinetics. Given the inconsistent data, ongoing research should focus on clarifying the influence of CPB procedure and related clinical covariates on the pharmacokinetics of different antibiotics during cardiac surgery. Traditional prophylactic dosing regimens may need to be re-assessed to ensure sufficient drug exposures that will minimise the risk of surgical site infections.

National expenditure on health research in South Africa: what is the benchmark?

The Mexico (2004), Bamako (2008) and Algiers (2008) declarations committed the South African (SA) Ministry of Health to allocate 2% of the national health budget to research, while the National Health Research Policy (2001) proposed that the country budget for health research should be 2% of total public sector health expenditure. The National Health Research Committee has performed an audit to determine whether these goals have been met, judged by: (i) health research expenditure as proportions of gross expenditure on research and development (GERD) and the gross domestic product (GDP); and (ii) the proportion of the national health and Department of Health budgets apportioned to research. We found that total expenditure on health research in SA, aggregated across the public and private sectors, was R3.5 billion in 2009/10, equating to 16.7% of GERD. However, the total government plus science council spend on health research that year was only R729 million, equating to 3.5% of GERD (0.03% of the GDP) or 0.80% of the R91.4 billion consolidated government expenditure on health. We further found that R418 million was spent through the 2009/2010 Health Vote on health research, equating to 0.46% of the consolidated government expenditure on health or 0.9% of the R45.2 billion Health Vote. Data from other recent years were similar. Current SA public sector health research allocations therefore remain well below the aspirational goal of 2% of the national health budget. We recommend that new, realistic, clearly defined targets be adopted and an efficient monitoring mechanism be developed to track future health research expenditure.

Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism

Introduction It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes. Case Report A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered. Discussion Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.