Establishment Of Intensive Care Units Research Articles

Outcome and Associated Factors among Adult Tetanus Patients Admitted to Jimma University Medical Center: A Retrospective Study

Background: Although, tetanus is a vaccine preventable disease mortality remains high. And despite the establishment of intensive care unit in Jimma University Medical Center the overall mortality reaches up to 40%. This study will question why the outcome of patients has not improved despite the improvement in the setup of ICU and tries to come up with possible associated factors that prognosticated the outcome.
 Objective: The objective of this study will be to assess the outcome and factors associated with adult tetanus patients treated at JUMC, ICU from 1st Nov 2019 to 31st March 2021.
 Methodology: A retrospective cross-sectional study was conducted at JUMC on admitted patients with the diagnosis of tetanus. The study recruited all admitted patients from 1st Nov 2019 to 31st March 2021 at medical and surgical ICU. A structured checklist will be developed and the relevant information from the patients’ card will be entered in the structured checklist. Outcome will be defined as a binary variable (death, survival) independent variables will be examined for possible association with the dependent variable. Descriptive statistics like means, frequency and tabulations will be used.
 Conclusion: Tetanus has high case fatality rate. Prevention of tetanus could have minimized the mortality. Delayed health care seeking by patients had determinant role for management outcome.

Has Outcome of Subarachnoid Hemorrhage Changed With Improvements in Neurosurgical Services?

Background and Purpose- Though reports suggest decreasing fatality rates of subarachnoid hemorrhage with time, trends in outcome are not reported much especially from developing countries. This study was to analyze changes in outcome across 2 decades and elucidate probable factors. Methods- Prospective databases during 1996 to 2015 were reviewed for neurological outcome at 3 months in relation to demographics, Hunt and Hess grade, Fisher grade, and definitive treatment; and compared between 2 decades, contrasted by establishment of intensive care unit with continuous monitoring and other advancements. Univariate and multivariate analyses were performed. Results- Of the total 2039 patients, 1035 were managed in the former and 1004 in the recent decades. Compared with the former decade, there is delayed age at presentation (46 versus 49 years, P<0.001), poorer Fisher grades (81% versus 87%, P<0.001), and more patients with Hunt and Hess grade 2 (24% versus 39%, P<0.001) in the recent decade. While all patients in databases of the former decade had undergone clipping, 6% in the recent decade underwent coiling. 11% in the recent decade could not undergo definitive treatment. Despite this, there was significantly higher overall favorable outcome (50% versus 60%; odds ratio, 1.5; P<0.001) in recent decade. Favorable outcome of surgical clipping per se improved significantly from 50% to 67% (odds ratio 2.0; P<0.001). Though the improvement was across subgroups, it was more marked among Hunt and Hess grade 3 and Fisher grades 3 and 4. In multivariate analyses, both overall outcome (adjusted odds ratio, 1.7; 95% CI, 1.4-2.1; P<0.001) and surgical outcome (adjusted odds ratio, 1.8; 95% CI, 1.5-2.2; P<0.001) were significantly better in recent decade, independent of known prognostic factors. Conclusions- This is probably the first report to show independent improvement in outcome of subarachnoid hemorrhage with betterment in neurosurgical services from developing country. Dedicated intensive care unit care and focused management protocols could be the likely causes for improvement. Resource-constrained institutions may target patients in Hunt and Hess grade 3 and Fisher grades 3 and 4 for optimal intensive care unit utilization.

A Four Years Record Review of Tetanus Cases Admitted to Jimma University Specialized Hospital (JUSH), Southwest Ethiopia: A Slip of Tetanus Case Management?

Background: Establishment of Intensive care unit (ICU) at JUSH did not improve mortality of tetanus cases due to infrequent tracheostomy and mechanical ventilation. Objective: To assess the morbidity, management and mortality of tetanus cases admitted to JUSH between Jan. 2008 and Dec. 2011. Methods: Retrospective review of tetanus cases was conducted from Jan. to June 2012. A total of 45 patients were reviewed. Data collection format was used for each individual case to collect information that was recorded about each patient. Data was collected by senior medical students (year V) for 15 days. Training was given for 1 day for data collectors on data collection. Data was summarized and summary statistics were calculated using scientific calculator. Result: A total of 45 cases were obtained. Males accounted for 34(75.6%), 2(4.4%) were neonates and 22(48.9%) of all cases were aged between 11 and 30 years of age. None of the cases had prior immunization history for tetanus and 37(82.2%) had accessible wound. For all cases there was no evidence as to whether they sought health care for primal wound. The overall mortality was 18(40.0%). The Commonest portal of entry was traumatic wound 24(53.5%). The commonest site was lower limb, accounting for 26(57.8%). Twenty four (53.5%) had period of onset of less than 24 hours prior to admission. Twenty seven (60.0%) had incubation period of < 14 days. At admission, generalized spasm was found in 36(80.0%) of patients and it accounted for 17(94.4%) of all deaths. Eleven (61.1%) of all deaths occurred within the first three days of admission. Quality of care at ICU was unsatisfactory and management of fever and wound were neglected. Conclusion: Delayed health care seeking by patients was sacrosanct for management of tetanus. Quality of care at ICU was suboptimal. Management of fever and wound got less attention.

Pioneering early Intensive Care Medicine by the 'Scandinavian Method' of treatment for severe acute barbiturate poisoning.

Between the 1920s and the mid-1950s, barbiturates were the sedative-hypnotic agents most used in clinical practice. Their ready availability and narrow therapeutic margin accounted for disturbingly high rates of acute poisoning, whether suicidal or accidental. Until the late 1940s, medical treatment was relatively ineffective, with mortality subsequently high - not only from the effects of coma, respiratory depression and cardiovascular shock with renal impairment, but also from complications of the heavy use in the 1930s and 1940s of analeptic stimulating agents. Incidence of barbiturate intoxication increased substantially following World War II and this paper details development of what became known as the 'Scandinavian Method' of treatment, which contributed substantially to the earliest establishment of intensive care units and to the practice and methods of intensive care medicine. Three names stand out for the pioneering of this treatment. Successively, psychiatrist, Aage Kirkegaard, for introducing effective anti-shock fluid therapy; anaesthetist, Eric Nilsson, for introducing anaesthesiologic principles, including manual intermittent positive pressure ventilation into management; and, psychiatrist, Carl Clemmesen, for introducing centralisation of seriously poisoned patients in a dedicated unit. Clemmesen's Intoxication Unit opened at the Bispebjerg Hospital, Copenhagen, on 1 October 1949. ICU pioneer Bjørn Ibsen suggested it was the initial ICU, while noting that it supplied Intensive Therapy for one type of disorder only (as had HCA Lassen's Blegdam Hospital unit for Denmark's 1952 to 1953 polio epidemic). Treatment for barbiturate poisoning during the 1950s in some other Scandinavian hospitals will also be considered briefly.

Admissions and Outcomes of Intensive Care Management of Severe Head Injured Patients in Non-Neurosurgical Centres

Background: The admissions and outcomes of intensive care management of severe head injured patients depend not only on the standard and effectiveness of the treatment obtained but also on the available technical and human resources. We aimed at auditing the admissions and indeed the outcomes of severe head injured patients admitted in our non-neurosurogical centres. Patients and Methods: This was a retrospective review of the demographic, clinical with neurological data and outcomes of the management of all severely head injured patients admitted to the Intensive Care Units (ICU) of the Federal Teaching Hospital, Gombe and University of Maiduguri Teaching Hospital, Nigeria, for three year duration from January, 2007- December, 2009. Results: The total of 258 cases were retrieved and analyzed within the period under review. Two hundred and thirty one (n=231, 89.53%) were males and twenty seven (n=27, 10.47%) were females. The ages ranges between 1-70 years old with the mean ages of 31.29 (SD=15.66). The length of stay (LOS) from admission to discharge ranged from 1-29 days with the mean of 5.80 days (SD= 6.06) while, the LOS from admission to death ranged from 1-24 days with the mean of 3.62days (SD=4.14). Majority (91.8%) of the causes of the head injury were due to RTA with the mortality rates of 27.9%. Conclusions: A well equipped ICU would greatly facilitate the care of the severely head injured patients and can be an achievable goal in developing countries, if there is rational allocation of resources despite the prevailing challenges. We therefore, recommend the establishment of ICU in general and to encourage physicians to develop interest in the management of severely head injured patients even in a non-neurosurgical ICU.

The Effect of Critical Illness on Drug Distribution

The complexity of managing critically ill patients has increased since the early establishment of intensive care units in the 1950s. Despite of the fact that the number of drugs available to clinicians has increased, the understanding of the pharmacokinetics of individual drugs in specific disease states is still a matter of concern. Among the pharmacokinetic processes which may be affected in this patient population, drug distribution is a very important one. Changes in drug distribution may cause inadequate drug exposure at the infection site and consequently influence clinical outcome. Since drug distribution is dependent on a plethora of factors, including the physicochemical characteristics of the drug, we will focus on the most common mechanisms responsible for altered tissue distribution. These include changes in protein binding, fluid shifts, and pH changes. Although less common, alterations in organ perfusion may also play a role, particularly in heart failure patients. Despite great advances in understanding the distribution of antibacterial drugs, further studies are needed to define the consequences of changed drug distribution in critically ill patients on dosing regimens and clinical outcome.

A Clinical Commentary on the Article “Injectable Acellular Hydrogels for Cardiac Repair”

Left ventricular (LV) remodeling caused by a myocardial infarction (MI) is responsible for almost 70% of the five million cases of heart failure in the USA [1]. Over the past 50 years, the establishment of intensive care units, antiarrhythmic drugs, and reperfusion therapy has improved early survival after acute MI. This success has paradoxically contributed to the increased incidence in heart failure. While the use of optimal pharmacologic therapy can slow the progression to heart failure after MI, the incidence of the disease continues to grow, and survival rates, once clinical symptoms appear, have not increased appreciably since the 1970s [2]. The outlook for patients with end-stage heart failure remains particularly poor. Dissatisfaction with the treatment options for end-stage heart failure has resulted in an increased interest in developing interventions that can be implemented early after MI with the intent of slowing or arresting the progression to heart failure. Cellular therapy with any number of cell lines has been championed by many investigators as a possible means of regenerating myocardium and ameliorating adverse LV remodeling after MI. In spite of extensive enthusiasm for this therapeutic approach, regeneration of electromechanically integrated myocardium in the infarct zone has never been demonstrated to occur in patients or in large animal infarct models.

Case-fatality of adult tetanus at Jimma University Teaching Hospital, Southwest Ethiopia.

Tetanus remains a major health problem in Ethiopia like in most other developing countries. To assess the clinical presentation, complications and outcome of tetanus patients. In this retrospective study, patients (age > 13 years) who were admitted to Jimma University Teaching Hospital from 1996 to 2009 were included. Data from 171 patients were analyzed (129 males, 42 females, mean age 33 years). The mean hospital stay for patients discharged cured and deceased was 21.5 ± 12 and 6.5 ± 6.7 days, respectively. None of our patients was immunized for tetanus. Tracheostomy and mechanical ventilation (MV) was done in 10.5% and 11 %, respectively. The case-fatality was 38%. The mean annual admission and case-fatality increased over the study period from 9 to 20.5 and from 21 % to 51%, respectively. Establishment of intensive care unit (ICU) did not improve mortality due to infrequent tracheostomy and MV. The case-fatality was high like in most other studies and the majority of patients died in the first few days indicating that adequate respiratory support was not given. Establishment of ICU did not improve mortality. Tetanus can be prevented by vaccination and if it occurs it needs well equipped ICU.

Acute respiratory distress syndrome: a historical perspective.

Though well described even in ancient writings, the acute respiratory distress syndrome (ARDS) gained major medical attention with the availability of mechanical ventilation and establishment of intensive care units. In the 50 years since this beginning there have been remarkable advances in the understanding of the etiology, physiology, histology, and epidemiology of this often lethal complication of common human maladies. Until recently, improvements in outcome have mainly followed improvements in intensive care unit operation and their associated life support systems, and have not come through discoveries made in the course of prospective randomized trials. In spite of the remarkable increase in research focused on ARDS, there remain a large number of unanswered clinical questions that are potentially extremely important with regard to short-term morbidity as well as long-term outcome. The ARDS Clinical Trials Network study of tidal volume has proven that randomized trials in ARDS with positive results are possible even when using difficult primary outcome measures such as mortality or ventilator-free days. Therefore, the rich combination of new trial strategies, potential treatments, experienced investigators, and increasingly standardized routine care set the stage for rapid advances to be made in the short- and long-term outcomes of this devastating syndrome.

Impact of improved perinatal care on the causes of death.

A total of 440 perinatal deaths occurring in a maternity hospital over a 6 year period have been analysed clinically and pathologically. The decline in mortality could be attributed to a reduction in asphyxial deaths, lethal malformations, and macerated stillbirths. The establishment of a neonatal intensive care unit seemed to have been more successful in combating birth asphyxia than respiratory distress syndrome. Although the greatest reduction in perinatal mortality was in babies with birthweights between 1 and 1.5 kg, there was no decline in the deaths from hyaline membrane disease or intraventricular haemorrhage, or both. The most striking change was the drop in asphyxia as a cause of perinatal death which was independent of birth trauma. Earlier diagnosis of fetal distress with obstetric intervention and the establishment of the intensive care unit were seen as the main factors in this change, and their mutual dependence and evolution are emphasised.

Esophageal atresia in the underweight baby: a challenge.

Abstract There has been a progressive improvement in the survival rate of underweight babies treated by a one-stage primary esophagoesophagostomy due to improved surgical technique, better understanding of the physiology of the small baby; better preoperative preparation, anesthesia, and postoperative, and nursing care; and the establishment of intensive care units. Only the most desperately ill babies and the very small babies with severe respiratory problems and/or a number of gross associated anomalies are managed in stages. The fact that the baby is small is not in itself sufficient reason to deprive him of the benefits of a one-stage primary repair of the anomaly.

Psychiatric Consultation in an Intensive Care Unit

Recent years have seen the establishment of intensive care units (ICUs) in general hospitals, where medical treatment requiring constant supervision and intensive nursing care can be given. Another recent development is the interest in the use of a psychiatrist in the general hospital, especially for consultation on problems arising with medical and surgical patients. However, no publication dealing specifically with consultation to an ICU has come to my attention. There has been a shift in the focus of psychiatric consultation which parallels certain developments in at large. Recently, psychiatry has come upon the scene. This article describes the application of some of its principles to psychiatric consultation. The leverage point for the community psychiatrist is not so much the individual patient as the various care-giving persons in the community, to whom he acts as a mental health consultant. Direct interaction with patients is less his concern than indirect