Gillian Bishop

Antecedents to hospital deaths

Background: Recent studies have suggested there are a large number of potentially preventable deaths in Australian hospitals.

Clinical examination is an inaccurate predictor of intraabdominal pressure.

This study was designed to establish if clinical examination can accurately predict intraabdominal pressure (IAP). Between August 1998 and March 2000 a prospective blinded observational study of postoperative intensive care unit patients was undertaken at a major trauma center. IAP was measured using an intravesicular technique and compared with clinical evaluation. An IAP of at least 18 mmHg was considered elevated. The sensitivity, specificity, positive predicative value (npv), negative predictive value (npv), kappa score, and reliability analysis were calculated. A total of 110 patients provided 150 estimates of IAP, which was elevated in 21%. The kappa score was 0.37; sensitivity, 60.9%; specificity, 80.5%; ppv, 45.2%; npv, 88.6%. The mean difference in IAP values between intravesicular readings and clinical estimates was −1.0±4.1. Prediction of IAP using clinical examination is not accurate enough to replace intravesicular IAP measurements.RésuméLe but de cette étude a été d’établir si l’examen clinique peut prédire avec précision la pression intra-abdominale (PIA). Entre août 1998 et mars 2000 on a entrepris une étude observationnelle prospective à l’insu des patients post-opératoires en soins intensifs (SI) hospitalisés dans un centre de traumatologie majeure. La PIA a été mesurée par la technique intravésicale et comparée à l’évaluation clinique. On a considéré qu’une PIA ≥ 18 mmHg était «élevée». On a calculé la sensibilité (Se), la spécificité (Sp), la valeur prédictive positive (VPP), la valeur prédictive négative (VPN), le score kappa, et la fiabilité. On a estimé cliniquement la PIA 150 fois chez 110 patients. La PIA était élevée dans 21% des cas. Le score Kappa a été de 0.37, la Se de 60.9%, la Sp, de 80.5%, la VPP de 45.2%, la VPN, de 88.6%. La différence moyenne en PIA entre la valeur intra-vésicale et l’estimation clinique a été de −1.0±4.1. La prédiction de la PIA par examen clinique n’est pas suffisamment précise pour remplacer la mesure par pression intravésicale.ResumenEl objetivo del estudio fue averiguar si la exploración clínica permite evaluar con exactitud la presión intraabdominal (IAP). Entre agosto de 1998 y marzo de 2000, se efectuó un estudio prospective ciego, durante el postoperatorio de pacientes ingresados en la UCI de un Centro Traumatológico de referencia. La IAP se midió mediante la técnica intravesical comparandose con los hallazgos clínicos obtenidos. Se consideró que la presión estaba elevada cuando la IAP era ≥18 mm Hg. Comprobamos: la sensibilidad, especificidad, valor predictivo positivo (ppv) y negativo (npv), la puntuación de Kappa y la fiabilidad de los análisis. La puntuación de Kappa fue de 0.37, la sensibilidad del 60.9%, especificidad 80.5%, ppv 45.2% y npv 88.6%. La diferencia media entre los valores de la IAP registrados mediante sonda intravesical y los estimados por la exploración clínica fueron de −1.0±4.1. La valoración clínica de la IAP no es lo suficientemente precisa como para reemplazar la medición intravesical.

Redefining in-hospital resuscitation: the concept of the medical emergency team

Cardiopulmonary resuscitation (CPR) has evolved over centuries with the greatest progress being made in the last 4 decades [1]. In 1958 and 1960 key advances were described by Safar [2] and Kouwenhoven [3] which have now become the basis for modern day basic life support (BLS) CPR. Extending BLS, advanced life support (ALS) guidelines have been developed to deal with the complex scenarios that result in and accompany cardiac arrest situations [4–6]. Cardiopulmonary resuscitation (CPR) is accepted practice for sudden in-hospital and out of hospital death. Cardiopulmonary resuscitation has become something of an industry. There are international organisations and conferences on resuscitation, numerous textbooks are written on the subject and journals, such as Resuscitation, are dedicated to improving resuscitation outcomes. Resuscitation features increasingly in the lay media. Television medical dramas commonly feature CPR. Interestingly, the results of television CPR are usually shown as successful and unrealistic in the US while in the UK the TV outcome is more likely to be bad and realistic [7,8]. The general public perception of outcome following CPR is overoptimistic while unfortunately CPR is usually a perimortem event. A recent review stated that CPR will be futile in some victims of cardiac arrest [9]. In fact, the majority of patients requiring in-hospital CPR die before hospital discharge. Survival to discharge rates after in-hospital CPR vary from 1 to 2% [10] to around 14% [11,12]. Other studies indicate survival figures between these figures [13–19]. It is interesting to note that there has not been a demonstrated improvement in general mortality rates after in-hospital CPR over the last 30 years. This is in spite of the enormous resources devoted to CPR in terms of education, research and the clinician’s time as well as refinements and developments related to CPR. Cardiopulmonary resuscitation has become something of a medical icon. Most are enthusiastic about its use in spite of the poor outcomes, few have urged restraint [20–22]. Increasingly there * Corresponding author. Present address: Division of Critical Care, The Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.

Problems following discharge after intensive care

Intensive care units (ICUs) are now present in most acute care hospitals. While long-term studies on patients admitted to these units have been performed to identify mortality, functional outcome and quality of life, there is little information on the recovery period in the weeks immediately following discharge. The aim of this study was to identify and describe the sequelae found in patients at 3 months after leaving the ICU. The study was conducted over a 6-month period during 1991, in a university teaching hospital in Sydney, Australia. 54 patients with a length stay (LOS) of greater than 48 hours in the ICU were included. Each patient was interviewed in an outpatient clinic attached to the ICU. Information collected included pre-admission details, reason for admission, treatments provided and complications encountered. General health state, social and employment details, functional status, referral patterns since discharge and recollection of ICU stay were studied. The major findings indicated that many of the patients interviewed were returning towards near normal general health, but were suffering mild to moderate physical and psychosocial sequelae. In the majority of cases the problems were not incapacitating. The predominant complaints were minor to severe pain, sleeping difficulties, tiredness and breathlessness. Financial problems were reported by a small number of patients. Depression, irritability or a feeling of loneliness were present in over one-third of the group. More than half the patients required referral for further assessment. 34% of patients had no recollection of their ICU stay. 16 patients (29.6%) reported unpleasant memories including nightmares and hallucinations.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory variation of intra-abdominal pressure : indirect indicator of abdominal compliance?

ObjectiveTo assess if the observed respiratory cycle-related variation in intra-abdominal pressure is reliably quantifiable and a possible indirect indicator of abdominal compliance. Secondary issues were to assess the roles played by respiratory parameters in determining this oscillation and by patients’ position in increasing their intra-abdominal pressure.Design and settingProspective observational study in a 26-bed medical-surgical intensive care unit.PatientsSixteen consecutive patients admitted to intensive care for at least 24 h, requiring mechanical ventilation and intra-abdominal pressure monitoring.Measurements and resultsIntra-abdominal pressure was measured with a modified Kron technique; its waveform was recorded and inspiratory and expiratory values were measured during five consecutive respiratory cycles for 5 days, both in the supine and the 30° head-up position. Inspiratory values were significantly higher than expiratory values (p = 0.001) and a correlation was found between their difference and intra-abdominal pressure basal values (p = 0.025). A positive linear relationship was shown between intra-abdominal pressure and the amplitude of its oscillation (r = 0.4), particularly in the subgroup of patients with intra-abdominal hypertension (r = 0.9). Intra-abdominal pressure was lower in patients supine than in the 30° head-up position (p = 0.001).ConclusionsRespiratory cycle-related variations in intra-abdominal pressure were specifically investigated, quantified and shown as linearly increasing with end-expiratory intra-abdominal pressure; this phenomenon could be explained by patients’ abdominal compliance status. Supine posture should be an important consideration in specific patients affected by intra-abdominal hypertension.

Patient Examination in the Intensive Care Unit

There is often a false sense of security when a patient is surrounded by all the paraphernalia of modern technology — a sense that physical examination and history in the presence of so much information and technology may be redundant. While we may intimidate the general public and impress our ‘low tech’ medical colleagues with our technology; it is only the indifferent critical care clinician who does not rely on thorough history taking and physical examination in the intensive care unit (ICU).