Michael Sugrue

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.

A prospective study of the performance of the trauma team leader.

This study assessed the performance of the trauma team leader in 50 consecutive trauma resuscitations at Liverpool Hospital over a two-month period. The trauma team consists of intensive care (ICU), emergency, and surgical registrars, three nurses, a wardsman, a radiographer, and a social worker. The team leader position alternates between the ICU and emergency registrar on a fortnightly roster. A panel of specialists experienced in trauma management evaluated 38 aspects of the initial resuscitation. Individual variables received different weightings. The maximum possible score for team leader performance was 80. The mean team leader score was 70.4 +/- 8 (SD). The main deficiencies in the team leaders performances were in their interpersonal communications and in the adequacy of documentation of the history of the injury. In 20% of resuscitations there were failures to completely expose the patient. Medical skills were uniformly well performed. Poor communication with other team members were the main pitfall of the team leader in this study. The team leader score may prove a useful tool in improving the quality of the trauma team.

RENAL IMPLICATIONS OF INCREASED INTRA-ABDOMINAL PRESSURE: ARE THE KIDNEYS THE CANARY FOR ABDOMINAL HYPERTENSION?

Abstract Introduction: Increased intra-abdominal pressure (IAP) or intra-abdominal hypertension (IAH) is a cause of organ dysfunction in critically ill patients and is independently associated with mortality. The kidneys seem to be especially vulnerable to IAH induced dysfunction and renal failure is one of the most consistently described organ dysfunctions associated with IAH. The aim of this paper is to review the historical background, awareness, definitions, pathophysiologic implications and treatment options for IAP induced renal failure. Methods: This review will focus on the available literature on IAH-induced renal dysfunction. A Medline and PubMed search was performed in order to find an answer to the question “What is the impact of increased IAP on renal function in the critically ill?”. The resulting references were included in the current review on the basis of relevance and scientific merit. Results: Renal dysfunction in IAH is a multifactorial process. The mechanisms involved have not been clarified completely. However, decreased cardiac output, altered renal blood flow and hormonal changes have been implicated. Decompression seems to have a beneficial effect on renal dysfunction, although there are some conflicting data. This may be due to the fact that there is no consensus on indications for decompression, both in terms of IAP values and of timing. An overview of current literature is provided and some interesting leads for future research are suggested. Conclusion: IAH can cause renal dysfunction. Therefore, IAP measurements should be considered in our daily practice and preventive measures should be taken to avoid (deterioration of) renal failure in patients with IAH. Decompression may have a beneficial effect in patients with established IAH and renal failure.

Potential cervical spine injury and difficult airway management for emergency intubation of trauma adults in the emergency department—a systematic review

Background: Emergency airway management for trauma adults is practised by physicians from a range of training backgrounds and with differing levels of experience. The indications for intubation and technique employed are factors that vary within EDs and between hospitals. Objectives: To provide practical evidence based guidance for airway management in trauma resuscitation: first for the trauma adult with potential cervical spine injury and second the management when a difficult airway is encountered at intubation. Search strategy and methodology: Full literature search for relevant articles in Medline (1966–2003), EMBASE (1980–2003), and the Cochrane Central Register of Controlled Trials. Relevant articles relating to adults and written in English language were appraised. English language abstracts of foreign articles were included. Studies were critically appraised on a standardised data collection sheet to assess validity and quality of evidence. The level of evidence was allocated using the methods of the Australian National Health and Medical Research Council.

RECOMMENDATIONS FOR RESEARCH FROM THE INTERNATIONAL CONFERENCE OF EXPERTS ON INTRA-ABDOMINAL HYPERTENSION AND ABDOMINAL COMPARTMENT SYNDROME

Abstract Objective. Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) have been increasingly recognized in the critically ill over the past decade, and the number of published studies has exploded in recent years. Interpretation of the results and comparison of these studies is difficult, because of incomplete and inconsistent reporting of data and statistics. Design. An international consensus group of multidisciplinary specialists convened at the third World Congress on Abdominal Compartment Syndrome to develop recommendations for research related to the diagnosis and management of IAH and ACS. Methods. Prior to the conference the authors developed a blueprint for consensus definitions and treatment guidelines which were refined both during and after the conference. Results. Three major types of studies were identified (measurement techniques, epidemiology, and interventions), each with different needs regarding methodology, reporting of data and statistical analysis. Conclusions These recommendations are proposed to guide clinical research in the field of IAH and ACS

Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence‐based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on‐call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on‐call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence‐based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non‐therapeutic laparotomy rates.

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.

Time for a change in injury and trauma care delivery: a trauma death review analysis

Safety and error reduction in medical care is crucial to the future of medicine. This study evaluates trauma patients dying at a level 1 trauma centre to determine the adequacy of care. All trauma deaths at a level 1 trauma centre between 1996 and 2003 were reviewed by an eight‐member multidisciplinary death review panel. Errors in care were classified according to their location, nature, impact, outcome and whether the deaths were avoidable or non‐avoidable. Avoidable deaths were categorized as potentially, probably and definitely avoidable. Between 1996 and 2003, there were 17 157 trauma admissions, including 307 trauma deaths. The mean patient age was 47.7 years ± 24.8 years, mean injury severity score 38.1 ± 19.6. Of all deaths, 69 (22.5%) were deemed avoidable. Of the avoidable deaths, 61 (88%) were potentially avoidable, 7 (10%) probably avoidable and 1 (1.4%) definitely avoidable. Avoidable deaths were associated with patients with increased age, lower injury severity score, admissions to intensive care unit, longer hospital stay and treatment by a non‐trauma surgeon (P < 0.05). Of the 307 trauma deaths, 271 (89.3%) patients experienced a total of 1063 errors, an overall error rate of 3.5 per patient. The error rate in the non‐avoidable group was 2.9 per patient and 5.3 per patient in the avoidable group (P < 0.0001). Most errors occurred in the resuscitation area. Age, severity of injury, hospital length of stay and care by a non‐trauma surgeon are factors associated with avoidable deaths. A new approach to trauma and injury care is required.

TRAUMA RECEPTION AND RESUSCITATION

The hospital reception phase of major trauma management requires a great number of expedient decisions. However, despite widely taught programmes advocating a standardized, algorithmic approach to decision‐making, there is an ongoing rate of human errors contributing to adverse outcomes. It is now time for a fundamental change in our approach to trauma resuscitation. Point‐of‐care computer technology linked to real‐time decision‐making and trauma team coordination may achieve error reduction through standardized decision‐making and a corresponding reduction in preventable mortality and morbidity.

Initial Management of the Poly-Trauma Patient: A Practical Approach in an Australian Major Trauma Service

The initial management of the poly-trauma patient is of vital importance to minimizing both patient morbidity and mortality. We present a practical approach to the early management of a severely injured patient as practiced at Liverpool Hospital in Sydney, Australia. Specific attention is paid to innovations in care and specific controversies in early management as well as local solutions to challenging problems.