Ivan Joubert

Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma)

BACKGROUND The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements. METHODS Randomized, controlled, double-blind study of severely injured patients requiring >3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 30 days. RESULTS A total of 115 patients were randomized; of which, 109 were studied. For patients with penetrating trauma (n=67), the mean (sd) fluid requirements were 5.1 (2.7) litres in the HES group and 7.4 (4.3) litres in the saline group (P<0.001). In blunt trauma (n=42), there was no difference in study fluid requirements, but the HES group required significantly more blood products [packed red blood cell volumes 2943 (1628) vs 1473 (1071) ml, P=0.005] and was more severely injured than the saline group (median injury severity score 29.5 vs 18; P=0.01). Haemodynamic data were similar, but, in the penetrating group, plasma lactate concentrations were lower over the first 4 h (P=0.029) and on day 1 with HES than with saline [2.1 (1.4) vs 3.2 (2.2) mmol litre⁻¹; P=0.017]. There was no difference between any groups in time to recovery of bowel function or mortality. In penetrating trauma, renal injury occurred more frequently in the saline group than the HES group (16% vs 0%; P=0.018). In penetrating trauma, maximum sequential organ function scores were lower with HES than with saline (median 2.4 vs 4.5, P=0.012). No differences were seen in safety measures in the blunt trauma patients. CONCLUSIONS In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma. STUDY REGISTRATION ISRCTN 42061860.

ICU-Associated Acinetobacter baumannii Colonisation/Infection in a High HIV-Prevalence Resource-Poor Setting

Background There are hardly any data about the incidence, risk factors and outcomes of ICU-associated A.baumannii colonisation/infection in HIV-infected and uninfected persons from resource-poor settings like Africa. Methods We reviewed the case records of patients with A.baumannii colonisation/infection admitted into the adult respiratory and surgical ICUs in Cape Town, South Africa, from January 1 to December 31 2008. In contrast to colonisation, infection was defined as isolation of A.baumannii from any biological site in conjunction with a compatible clinical picture warranting treatment with antibiotics effective against A.baumannii. Results The incidence of A.baumannii colonisation/infection in 268 patients was 15 per 100 person-years, with an in-ICU mortality of 26.5 per 100 person-years. The average length of stay in ICU was 15 days (range 1–150). A.baumannii was most commonly isolated from the respiratory tract followed by the bloodstream. Independent predictors of mortality included older age (p = 0.02), low CD4 count if HIV-infected (p = 0.038), surgical intervention (p = 0.047), co-morbid Gram-negative sepsis (p = 0.01), high APACHE-II score (p = 0.001), multi-organ dysfunction syndrome (p = 0.012), and a positive blood culture for A.baumannii (p = 0.017). Of 21 A.baumannii colonised/infected HIV-positive persons those with clinical AIDS (CD4<200 cells/mm3) had significantly higher in-ICU mortality and were more likely to have a positive blood culture. Conclusion In this resource-poor setting A.baumannii infection in critically ill patients is common and associated with high mortality. HIV co-infected patients with advanced immunosuppression are at higher risk of death.

User applied drug labels in anaesthesia: time for action

In 1985 Professor Pat Foster from Tygerberg Hospital under the auspices of the SA Society of Anaesthesiologists (SASA) and South African Bureau of Standards (SABS) pioneered the development of a national standard of colour-coded syringe labels for anaesthetic drugs. This colour coding system has been modified and adopted by authorities in Australasia, Canada, the United Kingdom and the United States of America.

Implementation of a postoperative handoff protocol

Background: Standardised handoff protocols have become necessary patient safety tools in the perioperative venue. In this study, the authors took a validated standardised perioperative handoff protocol and implemented it into their institution to improve the perioperative handoff communications from the cardiac operating theatres to the ICU. Methods: This was a prospective, unblinded cross-sectional study. During a 6-week pre-intervention phase, 30 perioperative handoffs were observed and data were collected. Then a new structured hand-off protocol was implemented for one month, which focused on training all participating healthcare providers. This was followed by a post-intervention audit consisting of 30 operating room theatre-to-ICU handoffs using the same methodology as the pre-intervention period. Results: Overall attendance significantly increased from 20% to 86.7%. The percentage of parallel conversations decreased from 100% pre-intervention to 60% post-intervention (p < 0.0001). The mean number of interruptions of the anaesthesiology handoff report decreased from 3.37 to 0.77 (p < 0.0001) and of the surgery report from 1.84 to 0.27 (p < 0.0001). Information-sharing scores improved among all handoff attendees with the Overall Information Sharing Score (OISS) increasing from 51.47% to 88.24% (p < 0.0001). Conclusions: The implementation of a perioperative handoff protocol resulted in a drastic improvement in attendance, decrease in the number of interruptions, and improved information sharing. Future research should focus on patient-specific outcomes.

Faulty risk-of-bias assessment in a meta-analysis of hydroxyethyl starch for non-septic ICU patients: a rebuttal

The Fluids in Resuscitation of Severe Trauma (FIRST) study meets all of the criteria for assessment as a low risk of bias study, contrary to the unsupported allegations by Bayer and Reinhardt. We dispute the letter from Bayer and Reinhart together with the response from He et al. [1]. Bayer and Reinhart claim that the FIRST study [2] has a high risk of bias and cite two non-peer-reviewed letters from themselves and Finfer to support this claim. However, these authors fail to cite the extensive responses that more than adequately cover their queries [3]. Bayer and Reinhart claim that there was selective outcome reporting, but all of the outcomes listed in the methods of the FIRST trial have been reported. As with all published work, space constraints imposed by the journal limit the amount of detail that can be included. In our paper all statistically significant results were reported in detail and other outcomes that were not significant were only reported briefly as is the norm. These non-significant outcomes were more than adequately addressed in the subsequent correspondence. There is therefore no basis for the claim that this study shows a high risk of bias. Indeed, in the initial letter from Bayer and Reinhart, their own bias is clearly illustrated in their attempts to draw inferences from non-significant data. In our view, the FIRST study meets all of the criteria for assessment as a low risk of bias study and we dispute the concession made by He et al. [4] regarding the risk of bias of this study. Our view is that the original analysis in the published paper reflects the correct scientific position and that the modified Jadad score of 6 allocated to this study is appropriate.

The pitfalls of postoperative theatre to intensive care unit handovers: a review of the current literature

Postoperative handovers present a critical step in the management of intensive care unit (ICU) patients. There are many challenges in the transportation of unstable patients with complex medical histories from theatre to the ICU, and the subsequent transfer of responsibility for care from one group of caregivers to another. Communication between the providers of the handover report (anaesthetists, surgeons and theatre nursing staff) and receivers of the report (ICU physicians and ICU nursing staff) is often poor. The unstructured presentation of information, the noisy ICU environment, and discussions between healthcare workers from different disciplines at different levels of training adds to the burden of communication. The handover report may be seen as a sentinel event in the ICU patient’s stay. ICU staff use the handover process as an important source of information to coordinate management input from multiple disciplines. Despite its importance, the practice of a structured postoperative handover protocol in our region’s hospitals is non-existent. The authors reviewed the current literature to better understand the challenges facing proper handover processes and suggest some interventional strategies.

Evidence-based approach to the use of starch-containing intravenous fluids: an official response by two Western Cape University Hospitals

Circular 114/2013 issued by the Western Cape Pharmacy Services entitled, Suspension of use of infusion solutions containing hydroxyethyl starch at Western Cape Government Health Facilities until further notice, resulted in the the non-availability of starch-containing solutions for clinical use. The reasoning behind the circular was based on the Medicines and Healthcare Products Regulatory Agency (MHRA) class 2 recall of starch solutions and the European Medicines Agency’s Pharmacovigilance Risk Assessment Committee, who stated that: “The benefits of infusion solutions containing hydroxyethyl starch no longer outweigh the risks, and (we) therefore recommend that the marketing authorisations for these medicines are suspended”. The two Western Cape University Hospitals have responded with a joint statement which is presented to SAJAA readers. The statement suggests withdrawals of corn-based starch solutions are based on flawed interpretation of the available data, particularly the suggestion that they cause renal dysfunction. The statement then interrogates why the use of corn-based starch solutions benefits patient care and improves outcome. Lastly, the problems of the alternative therapeutic options are examined. The conclusion reached is that the use of corn-based starch solutions should be reinstated. We believe this well-researched, evidence-based approach is worth publishing to a wider audience.

The assessment of intravascular volume

There are numerous reasons for the accurate assessment of intravascular fluid volume status. Some of the most often cited are: concerns regarding urine output, considerations for organ and tissue perfusion or even a desire for optimising fluid status, per se. Most practitioners agree that an underlying theme is the goal of attaining optimal cardiac output, either in the surgical setting or in intensive care. Intravenous fluid loading is often used as first line therapy for patients with hypotension or circulatory failure, but cardiac output responds positively after fluid challenge in only half the patients. For the remainder of patients fluid loading may be associated with adverse consequences.