ITU Admission Research Articles

Controversies in the management of deep neck space infection in children: an evidence‐based review

Deep neck space infection (DNSI) is defined as infection in the potential spaces and fascial planes of the neck. Early recognition of DNSI can be challenging due to the complex head and neck anatomy; hence, a high index of suspicion is required to prevent a delay in diagnosis and appropriate management. There remains a lack of consensus on the management of paediatric DNSI with many advocating a more aggressive approach with immediate surgical drainage, while others favour a more conservative approach with medical management in the first instance. The current literature on the management of paediatric DNSI is reviewed. A literature review performed in November 2015 searched PubMed using the terms 'deep neck space', 'infection', 'paediatric', 'pediatric', 'children', 'imaging', 'conservative', 'antibiotic' and 'surgery'. Articles not in the English language were excluded. (i) Clinical presentation: Management of a compromised airway is the priority. Clinical history and examination enables the identification of the primary source of infection and presence of complications. (ii) Investigations: Laboratory and microbiological investigations should be appropriately targeted, and CT imaging is the modality utilised in most cases. The presence of specific complications may warrant other imaging modalities. (iii) Antibiotics: An evidence-based antibiotic regime is proposed. (iv) Conservative treatment: In children lacking indications for surgical intervention, a trial 48 h of intravenous antibiotics (IV Abx) should be commenced. v) Surgical intervention: Indications include signs of airway compromise, presence of complications, no clinical improvement after 48 h of IV Abx, abscess >2.2 cm on CT imaging, age <4 years and ITU admission. An appreciation of head and neck anatomy is vital to understanding disease pathology and potential complications of DNSI, which may be life threatening. Both conservative and surgical approaches are viable treatment options and may compliment each other. Current evidence suggests that clinical management should be targeted towards the individual patient as factors such as age of the child may influence the balance of a conservative versus a surgical approach.

Hiv infected patients in intensive care: an observational study of admissions between 1996-2006 and 2007-2014

With the advent of widely available HIV testing and the introduction of antiretroviral agents, life expectancy of HIV infected patients has increased. Historically patients with HIV requiring ITU admission had a poor outcome, with mortality up to 70% however in recent years ITU mortality rates have fallen ([1]). An aging population presenting with both HIV complications and non-HIV related disease combined with improved survival rates has implications for ITU management and prognostication.

PWE-202 Outcomes in patients with acute idiopathic pancreatitis

<h3>Introduction</h3> The management of acute idiopathic pancreatitis (AIP) remains a challenge. There are no strong recommendations available to help with its management. Its impact on patient outcome is still not clear. Our aim was to compare the outcomes between patients presenting with AIP to those with acute non-idiopathic pancreatitis (NIP). <h3>Method</h3> A retrospective data collection was performed for all patients presenting with acute pancreatitis in a district general hospital during a 4-year period between January 2011 and December 2014. Data was collected using electronic patient records. Patient demographics, aetiology of pancreatitis and outcomes for all patients were analysed. Outcomes were defined as mortality due to acute pancreatitis, ITU admission, pancreatic necrosis and multi organ failure. <h3>Results</h3> During the 4-year study period 569 patients were diagnosed with acute pancreatitis. Out of all the patients 142/569 (25%) were diagnosed as having AIP. There was no significant difference in mean age in the two groups (AIP 59yrs; NIP 60yrs). There was a significantly higher incidence of female patients diagnosed with AIP (63%) compared to the NIP group (51%; P = 0.012). Twenty-one out of 142 patients with AIP (15%) had overall poor outcomes compared to 30/427 (7%) patients in the NIP group (OR 2.29; 95% CI 1.27 – 4.16; P = 0.006). AIP has significantly poor outcome compared with NIP for pancreatitis specific mortality (OR 3.79; CI 1.70 – 8.38; P = 0.0001), ITU admission (OR 2.73; CI 1.36 – 5.46; P = 0.003) and multi organ failure (OR 2.97; CI 1.36 – 6.49; P = 0.004). <h3>Conclusion</h3> Patients with IP have a significantly higher morbidity and pancreatitis specific mortality compared with NIP. This reflects our lack of understanding about the mechanisms that trigger pancreatitis in this group of patients. In addition, a more vigorous management pathway needs to be established to optimise the investigations and further management of this high-risk group of patients. <h3>Disclosure of interest</h3> None Declared.

PWE-093 Is cholecystostomy a good alternative treatment for acute cholecystitis in high risk patients?

<h3>Introduction</h3> Cholecystectomy is the treatment of choice for acute cholecystitis whose management in high risk surgical patients could be a difficult dilemma. With the development of interventional radiological skills, percutaneous cholecystostomy (PCS) could represent a less invasive option. <h3>Method</h3> This is a retrospective single Centre study; data were collected from our hospital electronic record system. From February 2009 to March 2014 there were 353 patients admitted with acute cholecystitis. Of these 39 were considered high risk for surgery and underwent PCS during their hospital stay. The radiological approach was trans-peritoneal in 29 patients and trans-hepatic in 10 patients. Median follow-up was 19 months. Aim of the study was to assess the outcomes of percutaneous cholecystostomy in high risk patients. <h3>Results</h3> There were 27 male (69.2%) and 12 female (30.8%) with mean age of 72 years (range 41–90 yrs). Twenty seven patients had PCS as definitive treatment (group A) and 12 patients as a bridge to cholecystectomy (group B). There were no post-procedures complications. Three patients in group B required conversion to open surgery (25%). Mean length of hospital stay was 15.7 days (group A and B). ITU admission was required for 8 patients (20.5%). Five patients in group A were readmitted once with another episode of cholecystitis after PCS (18.5%), with a median time to readmission of 85 days (3 patients readmitted within 90 days). One patient in group B was readmitted with cholecystitis after 2 years before proceeding to cholecystectomy, and 2 patients were readmitted after cholecystectomy (16.6%) for intra-abdominal collections treated with percutaneous ragiological drainage. Seven patients died (17.9%) as a result of severe biliary sepsis during their index hospital admission. <h3>Conclusion</h3> PCS is a safe approach in high risk patients with acute cholecystitis and can provide satisfactory long-term results when cholecystectomy is not a viable option. <h3>Disclosure of interest</h3> None Declared.

PWE-127 Trends In Hospital Admissions With Alcohol Related Liver Disease In South-east England

IntroductionMorbidity and mortality from alcohol related liver disease (ALD) has increased significantly in England. We aimed to assess the impact of the change in the alcohol licensing law in 2005...

PTH-015 Post-ercp Pancreatitis In Secondary Care: Can We Predict Who Would Benefit From A Prophylactic Pancreatic Stent?

IntroductionPancreatitis is a recognised complication of ERCP. Measures taken to reduce the incidence in high-risk patients include placement of prophylactic pancreatic stents and use of NSAIDs, but current practice varies...

Impact of consultant-led care in early pregnancy unit

Early pregnancy complication remains a significant cause of maternal morbidity and mortality. Despite the paucity of evidence to support consultant-led early pregnancy unit over nurse- or sonographer-led services, hospitals have devoted scarce resources to appoint consultants to lead their early pregnancy units. We compared the management and outcomes of confirmed and suspected ectopic pregnancy 1 year before and one year after the transition from a nurse-led to a consultant-led early pregnancy unit in a London hospital. Our study showed improvements in the rates of negative laparoscopy, ruptured ectopic pregnancy during follow-up, need for laparotomy, ITU admission and length of stay and statistically significant reduction in operative intervention, without concomitant rise in morbidity or mortality in women with confirmed or suspected ectopic pregnancies.

Sepsis and multiorgan failure following TVT procedure

Tension-free vaginal tape (TVT), is a commonly performed, low risk procedure for treatment of stress urinary incontinence (SUI). Severe complications are rare, but can be potentially life threatening. We present a case of 66 year old patient who sustained bladder perforation at the time of TVT procedure and subsequently developed sepsis rapidly leading to multi-organ failure and triggering sequence of serious complications. During her inpatient stay she required ITU admission, emergency laparotomy, TVT mesh removal, bowel resection due to ischemic colitis and anticoagulation for pulmonary embolism. Despite of clinical picture of sepsis her microbiology tests were almost consistently negative. This case emphasise importance of awareness and quick recognition of TVT related complications. Patient ultimately survived and recovered thanks to timely and coordinated management by the multidisciplinary team of doctors.

PM.55 Developing and Defining Auditable Standards of Care For Obstetric Women Admitted to ITU: Completing the Audit Cycle

There are many reports and recommendations in maternity care with some confusion and lack of clarity. Standards are available from confidential reports in maternal deaths, Clinical Negligence Scheme for Trusts,...

PP.91 Rupture Uterus Following Previous Caesarean Section in the Second and Early Third Trimester of Subsequent Pregnancy

Three cases of antenatal/pre-labour uterine rupture in women with scarred uterus.Rupture uterus following lower segment caesarean section is rare occurrence.Rupture uterus is linked with abnormal implantation of the placenta, and...

Orthopaedic Patients Who Require Intensive Care Admission

The purpose of this study is to evaluate the causes, numbers, demographics and outcomes of all trauma and elective patients admitted under orthopaedic care but needed intensive care input during their inpatient stay. A retrospective case note study looking at all trauma patients admitted between January 2009 and August 2010 from a University Teaching Hospital that needed ITU admission during their inpatient stay. ITU records were cross matched with an orthopaedic trauma database to create a list of patients. 43 trauma patients were admitted to ITU from orthopaedic care during this 19 month period. These patients were then split into three categories 1) Trauma patients (one fracture) 2) Poly trauma patients (<2 fractures) 3) Transfers (Inter-hospital transfers). Within the “trauma” patients’ category, 25% of patients were admitted due to post-operative complications following hip hemi-arthroplasties, 17% due to wound debridement and soft tissue infection and 14% attributed to post-oprative complications following IMHS fixation. 30% of patients needed ITU input due to sepsis, 19% due to acute renal failure and 17% to respiratory failure.11 patients were categorised as “poly-trauma” patients. 55% of patients sustained a RTA whilst the rest were split between “fall from height” and “crush” injuries. 34% of these patients needed ventillatory support and inotropes. The mortality rate was highest and the length of stay in ITU was longer in the “trauma” cohort, 21% and 4 days respectively.Largest proportion of ITU admissions were due to post operative complications following hip surgery especially hemi-arthroplasties. However, a surprising group that emerged was the number of patients admitted to ITU who had metal work and soft tissue infections. This has highlighted the need for pre-operative optimisation and post-operative vigilance in patients with orthopaedic infections and hip fractures.

Supine percutaneous nephrolithotomy with endoscopic combined intrarenal surgery — results of the first one hundred patients from a single UK centre

Objective To review our experience using combined supine PCNL and simultaneous ureterorenoscopy (ECIRS: endoscopic combined intrarenal surgery) to treat renal calculi. Patients and methods Retrospective analysis of operative times, anaesthetic and surgical complications, and stone-free rates in patients who underwent PCNL and ECIRS in the Galdakao Modified Supine Valdivia position at a single centre between September 2007 and November 2011 was undertaken. Outcomes for those patients with BMI &gt; 30 and those with high ASA grade were compared to the remaining patient group. Results One hundred patients underwent 103 PCNL procedures. Thirty-one (31%) patients had BMI &gt; 30 while 48 (48%) had ASA grade III or IV. Mean ± S.D. operative time and hospital stay was 111.34 ± 36.92 min and 49.5 ± 18.6 h respectively with no demonstrable increase in either parameter for patients with high ASA grade or BMI. The overall PCNL stone-free rate was 87% with 13 needing a secondary procedure. Six patients had postoperative complications (three transfusions, two post-operative fever and one ITU admission for sepsis). Conclusions Supine PCNL incurs minimal anaesthetic morbidity. The GMSV position enables PCNL to be performed in the obese safely with high stone-clearance rates when combined with ECIRS thus decreasing the need for ancillary procedures such as ESWL.

S28 Is a pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery feasible?

Introduction and objectivesThe new BTS lung cancer surgery guidelines mention patient optimisation to reduce risk. Our aim was to develop a multi-stranded pragmatic rehabilitation programme for this group of patients,...

P214 Acute exacerbations of COPD: a review of resuscitation status and associations with prognostic factors in hospital admissions

<h3>Introduction</h3> Acute exacerbations of COPD are among the most common reasons for hospital admission in the UK. Exacerbations can lead to respiratory failure requiring ventilatory support, and so decisions regarding “escalation” or “ceilings” of treatment are often made early in admission. Such decisions on intubation are inevitably linked to decisions regarding resuscitation status. Prognostic factors should be used when making these decisions and FEV₁ should not be used exclusively. We reviewed admissions with exacerbations of COPD, categorised by resuscitation status, to see if there were differences in prognostic features between groups. <h3>Methods</h3> 53 acute admissions with exacerbations of COPD were reviewed between 1 December 2010 and 31 January. Groups were divided by resuscitation status: documented decision not to attempt resuscitation (DNR), no documented decision (NoD) and documented decision for resuscitation (ForR). Data were collected on individual prognostic factors; we then calculated prognostic indices against known criteria. P values were calculated using Mann–Whitney U test. <h3>Results</h3> The significant findings were that patients in the DNR group had lower FEV₁, more likely to have home oxygen and had a poorer functional status. Age, comorbidity, BMI and previous ITU admission were not found to be significantly different between the groups. When the prognostic indices were calculated the patients in the DNR group were found to have higher scores, correlating with poorer prognosis. <h3>Conclusions</h3> From the results we can infer which factors are being used for resuscitation decisions in patients with COPD. Functional status and home oxygen are most relied upon with FEV₁ somewhat less so. Age, comorbidity and BMI are not being taken into account, despite evidence to suggest they should be considered. We have also discovered that ADO and GSF are strong prognostic indicators for this cohort, although their application may not be appropriate (only two patients of the DNR group had a predicted 3-year mortality &gt;50% on ADO index). This may reflect other factors (such as patient choice) that we have not evaluated. We feel that as many prognostic factors as available should be considered when making decisions on resuscitation as ultimately, this may also be the decision not to intubate.

Inital Presentation and Referral of Diabetes Mellitus

Background: NICE recommended in 2004 that children with suspected type 1 diabetes mellitus should be offered same day referral to a paediatric diabetic multidisciplinary team. On initial presentation of Diabetes Mellitus screening bloods are recommended. Current practise in a Welsh DGH was compared to these guidelines. Methodology: A retrospective analysis of 71 patients in our unit over a ten year period (2000-10) was carried out. Case notes were analysed. Results: Most presentations were in winter and autumn months. Polyuria (85%), polydipsia (92%), weight loss(62%), lethargy(35%) were the main presenting symptoms. 20/71(28%) presented in DKA. 54/71 (76%) presented to general practitioner(GP). 17/71(34%) presented to Accident & Emergency. 13/54 (24%) who presented to GP were referred to paediatric team more than 24 hours of initial presentation. Of these 2 patients were booked for blood tests, 8 patients were not diagnosed and no action was taken for 3 patients. The mean HbA1c of these 13 patients was 11.4mmol/L compared to 10.4 mmol/L for the rest. 30% of these patients presented in DKA out of which 66% were severe DKA (pH < 7.1). All the Intensive Care Unit admissions were delayed referrals. Children who were referred late also had more days of hospital admission. Conclusions: Children who were referred more than 24 hours after initial presentation had higher HbA1c levels, were more likely to present in severe DKA, were hospitalised longer and had more likelihood of ITU admission. This analysis reiterates the importance of early recognition and referral of diabetes mellitus.

DIAGNOSIS AND MANAGEMENT OF SUSPECTED CASES OF SWINE (H1N1) INFLUENZA IN HULL AND EAST YORKSHIRE, UK

Introduction: A global influenza-pandemic was declared by the WHO in June 20091. In response to the challenges faced by the NHS, the DOH and the Health Protection Agency published pathways to guide the management of swineflu2’3. Hull and East Yorkshire Hospitals admitted many patients with suspected swine-flu. Several misdiagnoses were anecdotally noted. Here we evaluate our experience and highlight important lessons relevant for future influenza epidemics. Methods: A retrospective case-note review of individuals admitted with suspected swine-flu. We included those clinically diagnosed with swine-flu by GP, Pandemic-line and admitting team, between 1st June-31st August 2009. Results: 71 patients were identified over the study period, 51% were male, 49% were female; median age was 49. GP diagnosed swine-flu in 20%, 7% were diagnosed by the Pandemic-line, 66% in hospital. 6% were confirmed swine-flu. One required ITU admission. Table2 There was evidence of delay in final diagnosis and harm in 9 (12%) patients. 3 patients required admission to critical care facilities; one patient died. Table3 Discussion: Our review highlights potential delay in the final diagnosis and subsequent harm as result of concerns about swine-flu. At least in part, this is due the non-specific diagnostic criteria employed, resulting in number of false positive clinical diagnoses. Clinicians need to be aware of this possibility and consider alternative diagnoses even in the setting of pandemic. Across the NHS, it is likely that more patients were harmed as result of such delays, but it is unclear whether the swine-flu deaths prevented by the public health response outweigh the harm due to delay in alternative diagnoses. This problem should be considered in future pandemic planning.

Diagnostic and therapeutic utility of spyglass peroral cholangioscopy for indeterminate biliary lesions and bile duct stones

IntroductionPeroral cholangioscopy (POC) enables direct visual examination of bile ducts, tissue sampling and therapeutic interventions. The authors aimed to evaluate the diagnostic utility of Spyglass POC for indeterminate biliary lesions...

Mo1493 Delayed and Failed ERCP Significantly Worsen Outcomes of Patients With Acute Cholangitis

(81%) yielding sufficient samples whereas POC-directed biopsies were performed in 72/174 (41%) with 54/72 (75%) yielding sufficient samples. The sensitivity, specificity, positive and negative predictive values, and accuracy of POC with/ without tissue sampling for the diagnosis of malignant lesions were 70%, 97%, 93%, 87%, and 89%, respectively. Twenty-six out of 38 (68%) malignant lesions were correctly identified at Spyglass POC (with or without tissue confirmation). In all, 27 EHL procedures were performed in 25 patients. Bile duct clearance was achieved in 17/25 (68%) with a further 2/25 (8%) awaiting further procedures. There were 14/174 (8%) adverse events (9 cholangitis/sepsis, 1 postsphincterotomy bleed, 3 hypotension, 1 pancreatitis). Two adverse events were severe (1 death due to sepsis; 1 ITU admission due to pancreatitis), one moderate (sepsis) and the rest were mild.Conclusions In experienced hands, Spyglass POC is very accurate in the diagnosis of malignant biliary lesions and effective for the treatment of bile duct stones not amenable to conventional endoscopic therapy. The complication rate is comparable to that of conventional ERCP with sepsis being the most common adverse event.

Impact of Endothelial Activation on Infective and Inflammatory Complications after Cardiac Surgery in type II Diabetes Mellitus

Altered endothelial response has been described in diabetics after cardiac surgery. Infections and inflammatory organ damage often complicate the postoperative course. We evaluated endothelial/cytokine response (ECR) after cardiac surgery and its role on infective/inflammatory complications of type II diabetic patients. Perioperative ECR of 60 diabetic patients (Group A) undergoing cardiopulmonary bypass was compared to that of 60 non-diabetics (Group B). Hemodynamics, endothelial markers [vascular endothelial growth factor (VEGF) and monocyte chemotactic protein-1 (MCP-1)], pro-inflammatory (IL-2, IL-6, IL-8) and anti-inflammatory cytokines (IL-10) were analyzed preoperatively (T0), at time of aortic declamping (T1), at ITU admission (T2), at 12 h (T3) and 24 h (T4) postoperatively. Postoperative infective/inflammatory complications were registered, and the related ECR was analyzed. Hemodynamics were comparable. No differences were found in perioperative IL-6 (p = 0.776) and IL-8 (p=0.660) between the 2 groups. However, the diabetics showed significantly higher endothelial activation (VEGF p = 0.0001, p = 0.0001 since T1 to T3; MCP-1 p = 0.0001, p<0.007 at T1, T3 and T4) with lower IL-10 (p = 0.0001, p<0.05 at T2, T3, T4) and lower IL-2 secretion (p = 0.0001, p < 0.0001 at T1, T2). Infections developed in 23.3% of the diabetics; inflammatory complications in 13.3%. Those developing infections showed significantly lower IL-2 (p = 0.042; p = .021 at T1 and T2) than patients without infections, whereas those with complicated inflammatory lung or renal injury had higher MCP-1 leakage (p = 0.006) with lower IL-10 (p = 0.005). The diabetics showed higher endothelial activation and lower antiinflammatory response to CPB compared to non-diabetics. Infections in diabetic patients correlated with depressed IL-2, while inflammatory complications correlated to higher endothelial activation and lower anti-inflammatory cytokine secretion.

Oesophagectomies can be managed without routine HDU or ITU admission

Oesophagectomies can be managed without routine HDU or ITU admission