Southern African Journal of Critical Care最新文献

{"title":"Experiences of emergency care providers conducting critical care transfers in Gauteng Province, South Africa","authors":"A. Senekal, C. Vincent-Lambert","doi":"10.7196/SAJCC.2021.v37i3.487","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i3.487","url":null,"abstract":"Background Critical care transfer (CCT) involves the movement of high-acuity patients between facilities. Internationally, CCTs are commonly performed by a dedicated team using specialised vehicles and equipment. These transfers comprise a significant portion of the work of local ambulance services; however, there is a dearth of literature on current approaches and practices. Objectives To investigate and describe the experiences of a sample of Gauteng Province-based emergency care (EC) providers conducting CCTs. Methods A qualitative descriptive design used thematic analysis to gather data from 14 purposely selected participants during semi-structured focus group discussions, which were recorded and transcribed verbatim. Data were coded and analysed using ATLAS.ti to generate themes and sub-themes. Results The two dominant themes that emerged from the study were that there is no common understanding or clear definition of a CCT in the local context, and that systemic challenges are experienced. Participants indicated that their undergraduate training did not sufficiently prepare them to conduct CCTs. Local ambulance services appear to lack a common definition and understanding of exactly what constitutes a CCT and how this differs from ‘normal’ ambulance operations. Participants felt undervalued and poorly supported, with several systemic challenges being highlighted. Conclusion The absence of a contextually relevant definition of what constitutes a CCT, coupled with potential curriculum deficits in undergraduate EC programmes, negatively impacts on the experiences of EC providers conducting CCTs. Acknowledging CCT as an area of specialisation is an important step in addressing some of the frustrations and challenges experienced by EC providers tasked with conducting such transfers. Further research into formal postgraduate programmes in CCT is recommended. Contributions of the study This study provides insights into the experiences of South African emergency care providers conducting critical care transfers (CCTs). The research highlights a need to develop a common understanding and definition accepted by industry of what constitutes a CCT and how CCTs differ from primary response incidents, including the need for additional education and a focus on the conducting of CCTs.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46514891","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A retrospective evaluation of a multiplex polymerase chain reaction test directly applied to blood for the management of sepsis in the critically ill","authors":"S. Omar, S. Murphy, R. Gheevarghese, N. Poppleton","doi":"10.7196/SAJCC.2021.v37i3.495","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i3.495","url":null,"abstract":"Background Blood culture (BC) is the established gold standard for microbiological diagnosis of bloodstream infection (BSI); however, its sensitivity is poor. Objectives The primary objective was to determine the sensitivity and specificity of the Magicplex Sepsis Real-time Test, a multiplex polymerase chain reaction test (mPCR), and BC to detect BSIs. Secondary outcomes included determining the prevalence of BSIs. Methods A retrospective review of a technical evaluation of the mPCR. Patients requiring BC had a blood sample collected for mPCR Results The respective sensitivity and specificity of mPCR for the detection of BSI were 50% (n=7/14) and 58% (n=18/31), while the sensitivity and specificity using BC were 36% (n=5/14) and 68% (n=21/31), respectively. The addition of mPCR to BC increased BSI detection during sepsis from 36% to 64%. Conclusion The use of mPCR directly applied to blood may increase the detection of micro-organisms associated with BSIs in critically ill patients requiring BC investigation. Contributions of the study Our data add to a growing body of evidence indicating that mPCR applied directly to blood prior to incubation increases the detection of pathogenic bacteria among hospitalised patients for whom blood cultures are performed for suspected infection. Our study was performed in a low-to-middle income country with a higher sepsis prevalence, a greater burden of multidrug-resistant organisms and clinically defined sepsis. This strengthens the robustness and generalisability of this body of evidence.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49370483","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Critical care research in the resource-limited setting: Leveraging the power of the database","authors":"K. de Vasconcellos","doi":"10.7196/sajcc.2021.v37i3.530","DOIUrl":"https://doi.org/10.7196/sajcc.2021.v37i3.530","url":null,"abstract":"<jats:p>-</jats:p>","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45188885","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Failed extubation in a tertiary-level hospital intensive care unit, Pretoria, South Africa","authors":"L. G. Mogase, M. Koto","doi":"10.7196/SAJCC.2021.v37i3.446","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i3.446","url":null,"abstract":"Background A prospective cohort study sought to measure the incidence and outcomes of failed extubation in Dr George Mukhari Academic Hospital intensive care unit (ICU), as well as to identify possible factors associated with failed extubation. Methods Data were collected over a 6-month period from 1 July 2015 to 31 December 2015. Pre-intubation parameters recorded on the data collection sheet included secretions, Glasgow Coma Scale (GCS), fluid balance, Tobin index, partial pressure of carbon dioxide (pCO2 ), partial pressure of oxygen (PaO2 ), comorbidities and weaning method. Results A total of 242 patients were enrolled over the 6-month study period. Of the 242 patients, 86 were excluded owing to pre-set exclusion criteria (death before extubation; tracheostomy before extubation; re-intubation >72 hours post extubation). An extubation failure rate of 16.7% (n=26) was observed. The incidence of ventilator-associated pneumonia in the failed extubation group was 19.23%, whereas death was recorded in 42.31% of patients who failed extubation. The average length of ICU stay in the reintubated group was 11.58 days, and 4.04 days for successfully extubated patients. Only low GCS had a statistically significant impact on failed extubation: p=0.0025; odds ratio (OR) for low v. normal 5.13 (95% confidence interval (CI) 1.78 - 14.79). Other predictor variables measured did not reach statistical significance. Weaning method: p=0.3737, OR for No T-piece v. T-piece 1.65 (95% CI 0.547 - 4.976); comorbidities: p=0.5914, OR for two or more comorbidities v. no comorbidities 2.079 (95% CI 0.246 - 17.539), no comorbidities v. single comorbidity 0.802 (95% CI 0.211 - 3.043); fluid balance: p=0.6625, OR for negative v. positive fluid balance 0.571 (95% CI 0.170 - 1.916), OR for neutral v. positive fluid balance <0.001 (95% CI <0.001 - >999.999); pCO2 : p=0.7510, OR for high v. normal pCO2 1.344 (95% CI 0.346 - 5.213), OR for low v. normal pCO2 1.515 (95% CI 0.501 - 4.576); PaO2 : p=0.4405, OR for high v. normal 1.156 (95% CI 0.382 - 3.494); OR for low v. normal PaO2 2.638 (95% CI 0.553 - 12.587); Tobin index (Fischer’s exact test): p=0.7476. Conclusion Low pre-extubation GCS is a predictor of failed extubation. Contributions of the study The study is a prospective observational study conducted in a high-volume referral hospital. It adds valuable scientific information to a growing body of data on the topic of extubation failure. It further reinforces the importance of extubation failure and the requirement for due diligence to be paid before a patient is extubated.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48126380","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Alarms in the ICU: A study investigating how ICU nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, South Africa","authors":"A. Ramlaul, G. Chironda, P. Brysiewicz","doi":"10.7196/SAJCC.2021.v37i2.469","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i2.469","url":null,"abstract":"Background Advances in technology have facilitated the implementation of improved alarm management systems in the healthcare sector. There is a need to identify challenges encountered by intensive care unit (ICU) nurses with clinical alarm management systems in South Africa (SA) to ensure utilisation of these technological resources for patient safety. Objectives To investigate how intensive care nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, SA. Methods A descriptive, non-experimental research design using the census sampling strategy was used to invite 120 nurses from four ICUs to complete an adapted, structured questionnaire. Descriptive statistics were used to analyse the data. Results We had 91 respondents who completed the questionnaires (response rate of 75.8%). The majority of the respondents (85.7%) strongly knew the purpose of clinical alarms and 45.1% strongly felt confident about adjusting and monitoring the clinical alarms. More than half of the nurses (53.8 %) agreed to the existence of nuisance alarms that disrupted patient care (46.7%) and contributed to lack of responses (52.7%). While 76.9% strongly agreed with alarm sounds and displays to differentiate the priority of the alarms, 75.8% strongly agreed to the existence of proper documentation on setting alarms that are appropriate for each patient. The most frequent barriers were difficulty in setting alarms properly (51.6%) and lack of training on alarm systems (47.8%). Conclusion The complexity in setting the alarms, limited training and existence of false alarms was evident. Alarm-specific training is required to keep intensive care nurses updated with changes in technology to ensure patient safety. Contributions of the study The findings of this present study highlighted the importance of understanding the alarm management system within the ICU environment of the healthcare sector in SA. Technological improvements, specialised trainings and clear clinical policies for alarm management are essential to improve patient safety.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43847997","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"These are the (β, α, δ) days of our lives","authors":"P. Gopalan","doi":"10.7196/sajcc.2021.v37i2.507","DOIUrl":"https://doi.org/10.7196/sajcc.2021.v37i2.507","url":null,"abstract":"","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45681135","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The organisational response of a hospital critical care service to the COVID-19 pandemic: The Groote Schuur Hospital experience","authors":"W. L. Michell, I. Joubert, S. Peters, D. Fredericks, M. Miller, J. Piercy, C. Arnold-Day, D. Thomson, R. V. van Zyl-Smit, G. Calligaro, G. Strathie, P. Semple, R. Hofmeyr, D. Peters, K. Dheda","doi":"10.7196/SAJCC.2021.v37i2.503","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i2.503","url":null,"abstract":"Background There are limited data about the coronavirus disease-19 (COVID-19)-related organisational responses and the challenges of expanding a critical care service in a resource-limited setting. Objectives To describe the ICU organisational response to the pandemic and the main outcomes of the intensive care service of a large state teaching hospital in South Africa. Methods Data were extracted from administrative records and a prospective patient database with ethical approval. An ICU expansion plan was developed, and resource constraints identified. A triage tool was distributed to referring wards and hospitals. Intensive care was reserved for patients who required invasive mechanical ventilation (IMV). The total number of ICU beds was increased from 25 to 54 at peak periods, with additional non-COVID ICU capacity required during the second wave. The availability of nursing staff was the main factor limiting expansion. A ward-based high flow nasal oxygen (HFNO) service reduced the need for ICU admission of patients who failed conventional oxygen therapy. A team was established to intubate and transfer patients requiring ICU admission but was only available for the first wave. Results We admitted 461 COVID-19 patients to the ICU over a 13-month period from 5 April 2020 to 5 May 2021 spanning two waves of admissions. The median age was 50 years and duration of ICU stay was 9 days. More than a third of the patients (35%; n=161) survived to hospital discharge. Conclusion Pre-planning, leadership, teamwork, flexibility and good communication were essential elements for an effective response. A shortage of nurses was the main constraint on ICU expansion. HFNO may have reduced the requirement for ICU admission, but patients intubated after failing HFNO had a poor prognosis. Contributions of the study We describe the organisational requirements to successfully expand critical care facilities and strategies to reduce the need for invasive mechanical ventilation in COVID-19 pneumonia. We also present the intensive care outcomes of these patients in a resource-constrained environment.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47313164","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A review of the use of inhaled nitric oxide in the PICU at Red Cross War Memorial Children’s Hospital, 2011-2015: A retrospective cohort study","authors":"S. Padayachee, S. Salie","doi":"10.7196/SAJCC.2021.v37i2.416","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i2.416","url":null,"abstract":"Background Inhaled nitric oxide (iNO) functions as a selective pulmonary vasodilator. It is an expensive treatment that is often employed as rescue therapy for refractory hypoxaemia in acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT) following cardiac surgery. Objectives To describe the use of iNO and the cost of treatment in our paediatric intensive care unit (PICU). Methods A retrospective descriptive study of all patients treated with iNO in the PICU at Red Cross War Memorial Children’s Hospital (RCWMCH) from 2011 - 2015. Results We treated 140 patients with iNO, 82 for PHT following cardiac surgery, 53 for ARDS and 5 for persistent pulmonary hypertension of the newborn (PPHN). A response to treatment was observed in 64% of the cohort as a whole, 80% of those with PPHN, 67% of those with PHT post-cardiac surgery, and 64% of those with ARDS. A longer duration of PICU and hospital admission, and higher in-hospital mortality (53%), was seen in the group with ARDS, in particular those with adenoviral infection (63%), when compared with patients treated for PHT post-cardiac surgery (18%) and for PPHN (20%). The total cost of treatment with iNO was ZAR1 441 376 for the 5-year period studied. There are no protocols guiding the use of iNO in our unit, and it was found that response to treatment was not being objectively measured and documented, and that practice varied between clinicians. Conclusion Considering the cost of treatment and lack of evidence showing improved outcomes with iNO therapy, its continued use in our resource-limited setting should be guided by protocol. Contributions of the study There is a paucity of data regarding the indications for use, and outcomes of patients treated with iNO in resource-limited settings. We did not find evidence of improved outcomes in patients treated with iNO despite the high costs of the therapy. Protocols should be developed to guide the use of iNO in resource-limited settings.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":"37 1","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41715229","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The indications for and timing of haemodialysis in critically ill patients with acute kidney injury in Johannesburg, South Africa","authors":"P. Brown, L. Redford, S. Omar","doi":"10.7196/SAJCC.2021.v37i2.458","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i2.458","url":null,"abstract":"Background Acute kidney injury (AKI) is common among patients admitted to the intensive care unit (ICU). It is an independent risk factor for morbidity and mortality. The optimal timing of renal replacement therapy (RRT) remains unknown, resulting in a wide variation in observed current practices. There is a paucity of data on current practices within ICUs in South Africa. Objectives To describe current practices in the timing of RRT in patients with AKI admitted to the ICU. The secondary objectives were to describe the patient characteristics, severity of illness scores, staging at initiation of RRT, outcome at ICU discharge, and to estimate and describe delays in the initiation of RRT. Methods A retrospective, descriptive study was conducted in an adult academic ICU in Soweto from 1 January 2014 to 31 December 2015. Results There were 2 152 ICU admissions over the 2 years. Less than a tenth of the patients (3.5%; n=76) required RRT and the majority had sepsis (83%). The most common indication for RRT was oliguria/anuria (50%; n=38), followed by worsening urea/creatinine (29%; n=22), metabolic acidosis (11.8%; n=9), refractory hyperkalaemia (5.3%; n=4), fluid overload (2.6%; n=2) and other (1.3%; n=1). More than half of the patients (55%; n=42) had RRT instituted on admission day (D0 ), while 45% (n=34) had RRT initiated after D0 (D1-21). RRT was initiated at stage 3 AKI in 90% and 94% of D0 RRT group and D1-21 RRT group, respectively. The median (interquartile range (IQR)) time to starting RRT was 4 (4) hours once the decision to initiate RRT was made. The composite outcome of death, RRT dependence and diuretic dependence at ICU discharge was 21% and there was no difference between the two groups (p=0.22). The ICU mortality was 3%. Conclusion The sampled population was young, predominantly male and had post emergency surgery with a high burden of sepsis and HIV. The observed current threshold for RRT was late (stage 3 AKI with classic/emergent indications) with outcomes comparable with the reviewed literature. Contributions of the study The present study adds insight into the practice of initiating RRT in patients admitted to the ICU with AKI. These data have previously not been described in the South African context. The patient population differed from the literature in that they were young, predominantly male and had post-emergency surgery with a high burden of sepsis and HIV.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45534901","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Is there a role for melatonin in the ICU?","authors":"G. Richards, A. Bentley, P. Gopalan, L. Brannigan, F. Paruk","doi":"10.7196/SAJCC.2021.v37i2.490","DOIUrl":"https://doi.org/10.7196/SAJCC.2021.v37i2.490","url":null,"abstract":"Summary In the last decade, there have been significant developments in the understanding of the hormone melatonin in terms of its physiology, regulatory role and potential utility in various domains of clinical medicine. Melatonin’s purported properties include, among others, regulation of mitochondrial function, anti-inflammatory, anti-oxidative and neuro-protective effects, sleep promotion and immune enhancement. As such, its role has been explored specifically in the critical care setting in terms of many of these properties. This review addresses the physiological basis for considering melatonin in the critical care setting as well as the current evidence pertaining to its potential utility Contributions of the study This review examines and discusses the role of melatonin in the intensive care unit in terms of sleep, delirium and sepsis, both the physiology and as a therapy.","PeriodicalId":42653,"journal":{"name":"Southern African Journal of Critical Care","volume":" ","pages":""},"PeriodicalIF":0.4,"publicationDate":"2021-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49195602","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}