Satish Bhagwanjee

Management of sympathetic overactivity in tetanus with epidural bupivacaine and sufentanil: Experience with 11 patients

OBJECTIVE To determine the efficacy and safety of epidural bupivacaine and sufentanil for the management of sympathetic overactivity in tetanus. DESIGN Retrospective case review. SETTING Sixteen-bed surgical intensive care unit in a tertiary care centre. PATIENTS All patients referred to the unit during a 63-month period with the diagnosis of tetanus were included in the study. MEASUREMENTS AND MAIN RESULTS All patients (n = 11) had severe tetanus and developed sympathetic overactivity, which was managed by epidural blockade. Three patients died, but there were no fatalities directly attributable to sympathetic overactivity. Before epidural blockade, the average difference between the mean maximum and mean minimum systolic blood pressures was 78 +/- 28 (so) mm Hg. After blockade, this difference was reduced to 38 +/- 15 (so) mm Hg (p < .0001). Similar significant reductions in diastolic blood pressure and heart rate were observed. The mean hourly infusion doses of bupivacaine and sufentanil were 17 mg and 21 microg, respectively. Midazolam was the principal adjunctive sedative agent and was used in all patients (mean dose, 9 mg/hr). Additional pharmacologic agents were necessary in two patients in whom epidural blockade alone was insufficient to control sympathetic overactivity. One patient developed renal failure and there were no instances of pneumothorax. One patient developed an epidural abscess of probable hematogenous origin, which was successfully treated without neurologic sequelae. CONCLUSIONS Epidural blockade is effective in controlling sympathetic overactivity and the associated complications (renal failure, cardiac injury, and sudden death). Although a serious complication occurred in one patient, the efficacy of the technique deserves further validation.

Clinical research ethics for critically ill patients: A pandemic proposal

Pandemic H1N1 influenza is projected to be unprecedented in its scope, causing acute critical illness among thousands of young otherwise healthy adults, who will need advanced life support. Rigorous, relevant, timely, and ethical clinical and health services research is crucial to improve their care and outcomes. Studies designed and conducted during a pandemic should be held to the same high methodologic and implementation standards as during other times. However, unique challenges arise with the need to conduct investigations as efficiently as possible, focused on the optimal outcome for the individual patient, while balancing the need for maximal societal benefit. We believe that clinical critical care research during a pandemic must be approached differently from research undertaken under nonemergent circumstances. We propose recommendations to clinical investigators and research ethics committees regarding clinical and health services research on pandemic-related critical illness. We also propose strategies such as expedited and centralized research ethics committee reviews and alternate consent models.

Validation of an outcome prediction model for critically ill trauma patients without head injury.

BACKGROUND The Acute Physiology and Chronic Health Evaluation (APACHE) II system is inaccurate in predicting the risk of death in trauma patients, especially those without head injury. Using multivariate analysis of the APACHE II system in a development set, a new predictive equation was modeled. The four variables that were independently associated with mortality were PaO2/FiO2 ratio, mean arterial pressure, temperature, and the need for inotropic support. This model was tested prospectively in an independent validation set of 300 patients. METHODS Risk of death was calculated using the APACHE II system with the diagnostic category of multiple trauma and weighting for operative intervention as required. The new model was similarly assessed using the four predictor variables and their beta-coefficients for each mechanism of injury and the entire group. The predicted risk of death derived by both models was compared with the observed mortality rate. Discrimination was calculated using a 2 x 2 decision matrix with a decision threshold of r = 0.5 and receiver operating characteristic curves. Calibration was assessed graphically and by statistical correlation. RESULTS The observed mortality rate was 28.3% and the predicted mortality risk was 27.4% for the model and 6.26% for APACHE II. The sensitivity and specificity of the model were 58.8 and 90.7%, and the sensitivity and specificity of APACHE II were 1.2 and 100%. The areas under the receiver operating characteristic curves were 0.84 and 0.78 for the model and the APACHE II system, respectively. Calibration of the model was superior within all deciles of risk (model, R2 = 0.93, p < 0.001; APACHE II, R2 = 0.82, p = 0.02). CONCLUSION The model accurately predicted the risk of death for the entire group. It is superior to the APACHE II system and is the highest reported sensitivity for 24-hour intensive care unit predictive models that have been applied to the critically injured.

Ethics of Decision Making in Critical Care

This review will define the context of medical practice in the 21st century to highlight the challenge of managing patients with severe illness and at extremes of age where this was previously not possible. Equally, by virtue of the illness, these patients are often incapable of providing truly informed consent. For this reason there is a greater responsibility for the clinician to be the patient’s advocate. Patient autonomy is always the first imperative for the clinician but the need to be aware of and responsive to the other ethical tenets will be addressed.