ITU Admission Research Articles

A Phase II Study to Assess the Safety, Efficacy and Tolerability of Rituximab (Mabthera) In Combination with Plasma Exchange In Patients with Acute Thrombotic Thrombocytopenic Purpura (TTP).

AbstractAbstract 3699Idiopathic adult TTP is an acute life threatening disorder, in which antibodies, primarily IgG, are detected against ADAMTS 13. We undertook a a phase II trial in 40 patients between 2006-09 of Rituximab, 375mg/m2, weekly for 4 weeks, within 3 days of admission of acute TTP, in conjunction with standard therapy (PEX and steroids). Results have been compared to 40 historical controls (2000-2006), who had not received Rituximab, but had received other immunosuppressive treatments. The female to male ratio was 2:1, age 42 years (21-76), compared to 42 years (15-78) in the historical group. A third of trial patients required ITU admission and 15% were intubated and ventilated at presentation. One patient was withdrawn from the trial. Pre the 2nd Rituximab infusion, 68% had a platelet count >50 ×109/L and 38% >150 ×109/L. Six cases received more than 4 Rituximab infusions (maximum of 8), primarily non-Caucasian, guided by ADAMTS 13 assays. There was a significant reduction in days admitted in hospital in the Rituximab group (median 16.5 days) compared to historic controls (median 20 days) (p=0.04, Spearman correlation), specifically in Caucasian patients (12.5 V's 16 days-Rituximab V's Historical groups) (p=0.0005 Pearson Correlation). There was no overall significant difference in the number of PEX to remission. ADAMTS 13 activity on admission was median <5% (NR 55–126%). Median Anti ADAMTS 13 IgG was 40% (6-162%, NR:<4.2). Following 4 Rituximab infusions, median ADAMTS 13 activity was 43% (7-67%), median Anti-ADAMTS13 IgG was 12% (2-74%). In the historical group, 48% relapsed, median 18 months (3-60 months). In the Rituximab group, follow up 16–40 months, 10% relapsed, median 27 months (17-31). There were no excess infections in the Rituximab group. There were three deaths in the Rituximab cohort at days 11,15 and 25, due to progressive cardiac/neurological disease. In conclusion, Rituximab appears to be a safe and effective therapy given during acute TTP in conjunction with PEX and steroids. No significant difference was seen in the number of PEX to remission, compared to historical controls. However, there was a significant reduction in the number of days in hospital in the Rituximab group. The risk of relapse up to 40 months is significantly reduced in the Rituximab cohort. In patients with acute TTP, Rituximab should be considered in conjunction with standard therapy. Disclosures:Scully:MRC, BHF: Research Funding. Off Label Use: Rituximab, in TTP. McDonald:Baxter (uk): Research Funding. Machin:Baxter (UK), Bayer (UK), MRC, BHF: Research Funding.

468 Making a Difference: Introducing Paediatric Critical Care Outreach Supports Effectiveness of An Early Warning Scoring System Improving Patient Safety

Nottingham Children's Hospital has recently developed and introduced an integrated Paediatric Early Warning Scoring tool and Observation Chart. To support this development and to enable the structured escalation plan to be instigated, a PCCOT team was also introduced and trialled for one month. The aim of the trial was to find out what added benefit the PCCOT Nurse contributed to the PEWS system in the recognition and management of evolving critical illness thus enhancing patient safety. Other aims included improvement to the patient treatment pathway, to assess the types/range of skills the PCCOT Nurse needs and the level of activity of the PCCOT Nurse. Utilising a service redesign model the project has moved through the following stages: Problem Identification Identifying issues surrounding ‘failure to rescue’ Proposed initiative PEWS and PCOTT. Development of Tool - PEWS, observation chart and escalation plan. Pilot Stage The trial of PCOTT and new charts took place over 1 month. Results: Total Number of patients 137. Average Number of PCCOT episodes per day 20 Time spent per episode 15 min - 6 hours Average PCCOT episodes per patient 5 Patients admitted to PICU/PHDU had higher PEWS score. Of 15 patients admitted to a higher level of care the transfers were controlled and timely. During the trial there were no cardiac arrests on the wards and only one ‘collapse’ needing ITU admission from a ward where PCOTT had not been involved. Conclusion: Paediatric Critical Care Outreach supports the effectiveness of a PEWS System improving patient safety.

PONM23 The falling incidence of ITU admission in myasthenia gravis: does the early introduction of immunosuppression save lives?

The Greater Manchester Neuroscience Centre serves a population of 3.5 million. Between 1998 and 2009, 25 patients were admitted to the ITU with exacerbations of myasthenia gravis (MG), excluding those...

POC18 An encephalopathy worth its salt

A 67-year-old female was admitted to hospital with acute cholecystitis, she was treated with gentamicin and cefotaxime. She became confused and complained of flashing coloured lights in both visual fields....

P52 Neutrophil dysfunction: a potential biomarker of poor prognosis in acute liver failure?

IntroductionIn acute liver failure (ALF) an exaggerated systemic inflammatory response can result in neutrophil activation with subsequent tissue damage from release of proteolytic enzymes and reactive oxygen species, contributing to...

132 The utilisation of non-cardiac services by a heart attack centre

Introduction Most patients with ST-elevation myocardial infarction (STEMIs) within the London area are transferred to Heart Attack Centres (HAC) for primary percutaneous coronary intervention. HACs may be stand-alone centres, combined with cardiac surgery and cardiac ITU or part of a large single site acute hospitals. It is not clear whether these different models impact on patient pathways and care. We investigated the utilisation of non-cardiology services (including cardiac surgery and ITU) of patients admitted to a single London HAC. Methods We undertook a retrospective data analysis of 300 consecutive patients presenting with ST-elevation myocardial infarction to the London Chest Hospital, Barts and The London NHS Trust between January and June 2009. The cardiology databases and hospital care record systems were examined to identify all episodes and encounters generated by non-cardiology clinical activity. We also assessed use of cardiac surgery and intensive care during the index admission. Results Twelve (4%) of patients with STEMIs presenting to a HAC required clinical services outside the HAC infrastructure. 6 (2%) required either telephone advice or visit from a non-cardiac specialist and 6 (2%) required in-patient transfer to another clinical service. Inpatient transfer was due to complications of coronary intervention 3 (1%) or for management of newly diagnosed/ chronic non-cardiac conditions 3 (1%). No adverse outcomes were recorded due to delays in accessing non-cardiac care. ITU admission was required in 13 (4%) of HAC patients. The mean length of ITU stay was 11 days and the HAC service required an average of 0.8 ITU beds/day. Eighteen (5%) of HAC patients required inpatient CABG, 8/18 as emergency procedures. Conclusion Almost all STEMI patients can be managed within a HAC, and the utilisation of non-cardiac services is minimal suggesting that HACs can be located separately from acute general hospitals. However the importance of ITU and cardiac surgical services suggests that patient pathways are safer and more efficient if these services are on-site with the HAC. The greater risks of adverse outcomes following emergency surgery is another implication for surgical centres attached to the HAC.

2009 H1N1 influenza in pregnancy and reproductive-age women: a North East London experience

The 2009 H1N1 pandemic, only two months after its discovery, was an unprecedented event. Evidence suggests disproportionate disease with rapid deterioration in the young and pregnant, but is rapidly evolving...

The role of early C-RP levels in predicting outcome in patients with odontogenic infection

A large proportion of the oral-maxillofacial admissions are due to patients with odontogenc infection. Patients may display benign, or more severe, disease progression which may result in ITU admission, associated with increased morbidity and mortality rates.

Combined Lumbar Spinal and Thoracic High‐Epidural Regional Anesthesia as an Alternative to General Anesthesia for High‐Risk Patients Undergoing Gastrointestinal and Colorectal Surgery

A prospective study was undertaken to review the use of combined lumbar spinal and thoracic high-epidural regional anesthesia in high-risk patients who underwent gastrointestinal/colorectal surgery from 2004 to 2006. Twelve high-risk patients underwent 13 gastrointestinal/colorectal surgical procedures, using a regional anesthetic technique, which consisted of a thoracic epidural and lumbar subarachnoid block. All patients were classified as high risk based on anesthetic assessment (American Society of Anesthesiologists (ASA) score 3 or 4). Six (46.2%) of the patients were men, and the overall median age was 86 years. Ten (76.9%) patients presented as emergencies, whereas only three (23.1%) patients underwent elective procedures. All patients subjectively rated their postoperative pain relief as effective. The 30-day mortality was 2 (15.4%); however, both of these patients refused initial treatment. Only one (7.7%) patient required delayed ITU admission for respiratory support (CPAP). None of the patients required intubation at any stage. There were two (15.4%) minor and two (15.4%) major early complications and only one (7.7%) delayed complication to date. Median length of stay was 7 days. Two (15.4%) patients had delayed discharge dates, for social reasons. These patients demonstrated early postoperative recovery, with effective analgesia, no requirements for intubation, and lower morbidity and mortality rates than similar studies of high-risk patients who underwent procedures using general anesthesia. Using this technique, patients were managed appropriately in HDU and the surgical ward, without affecting their overall length of hospital stay. This study supports the role of regional anesthetic techniques, combined with targeted, minimally invasive surgery--particularly for the management of high-risk patients presenting in the emergency setting.

‘Liver function tests’ on the intensive care unit: a prospective, observational study

To evaluate the prevalence, patterns and significance of deranged liver function tests (LFT) in critically ill patients. A prospective, observational data collection of the LFT [bilirubin, alanine aminotransferase (ALT), alkaline phosphatase (AKP), gamma glutaryl transferase (gammaGT)] and critical care parameters in all admissions to the general intensive care unit (ICU) of our institution. Prevalence of abnormal LFT on the day of ITU admission is described and the relationship of abnormal LFT to clinical events and 30-day mortality analysed. Of 263 first admissions without hepatobiliary disease, 61% demonstrated an abnormal LFT at the point of admission. The majority of abnormalities were less than twice the upper limit of normal. Episodes of ventilation, haemofiltration and hypotension during the first 48 h were associated with an abnormal ALT on day 3. The presence of an abnormal ALT [odds ratio 2.7 (1.2-6.0)], AKP [OR 2.8 (1.1-7.3)] or gammaGT [OR 3.9 (1.9-8.3)] was associated with an increased risk of death within 30 days of admission. When adjusted for APACHE II score, LFTs were not independent predictors of mortality. Low-grade abnormalities of LFT are a significant entity in critically ill patients and show an association with mortality outcomes and clinical events on ICU. They are likely to represent part of a spectrum of liver injury associated with critical illness and should not be disregarded.

Inflammatory response to cardiopulmonary bypass with enoximone or steroids in patients undergoing myocardial revascularization: a preliminary report study

Recent reports have showed an antiinflammatory effect of phosphodiesterase III inhibitors (PDEi) in patients undergoing cardiopulmonary bypass (CPB). We sought to evaluate the immunological and hemodynamic response to enoximone and methylprednisolone in patients undergoing CABG. Prospective, randomized, controlled study. Cardiac surgery unit in a university hospital. 40 patients undergoing CPB-CABG. Patients receive enoximone (20, Group A) or methylprednisolone (20, Group B). Hemodynamic response was evaluated by Swan-Ganz catheter serial measurements and perioperative Lactate and Troponin I leakage, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpah, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3), 24 hs (T4) postoperatively. Morbidity and mortality were comparable between the two groups. Group A demonstrated higher cardiac index at T2 (2.93 l/min m2 vs 2.06, p < 0.001), at T3 (3.01 vs 2.18, p < 0.001), lower indexed systemic vascular resistance at T2 (2,044 dyne s cm-5 m-2 vs 3,132, p < 0.001). Except for higher TNF-alpha in Group B at T2 (15.89 vs 22.68, p = 0.005) proinflammatory cytokines were comparable. IL-10 was higher in Group B at any postoperative time (IL-10: T1 80.74 vs 143.3, p < 0.001, T2 165.7 vs 377.4, p < 0.001, T3 203.4 vs 443.5, p < 0,001, T4 251.8 vs 437.1, p < 0.001), whereas IL-4 and IFN-gamma proved higher in Group A at all time-points (IL-4: T1 45.9 vs 31.2, p = 0.008, T2 67.2 vs 39.7, p < 0.001, T3 77.9 vs 39.2, p < 0.001, T4 102.9 vs 42.2, p < 0.001. IFN-gamma: T1 25.8 vs 15.8, p < 0.001, T2 52.2 vs 30.3, p < 0.001, T3 78.4 vs 40.8, p < 0.001, T4 159.9 vs 67.4, p < 0.001). Despite comparable major clinical endpoints enoximone showed a different antiinflammatory pattern compared to methylprednisolone, however, the better hemodynamic response in enoximone compared to methylprednisolone suggests enoximone as a potential antiinflammatory tool to improve the outcome in cardiac surgery.

Towards a new standard of perioperative fluid management.

Recent studies suggest that current fluid strategies may result in excessive administration of both fluids and electrolytes. Perioperative fluid administration is dictated by an algorithmic approach, taking account of pre-operative deficit, maintenance requirements, and extrapolated third space losses. Salt and water overload is associated with pulmonary edema, ileus, and delayed wound healing. Within an intensive care population, there is a strong correlation between excessive intravascular volume and subsequent mortality, morbidity, and length of stay. Increasing weight has been shown to correspond with mortality, while achieving a negative balance within the first 72 hours of ITU admission has been postulated as an independent predictor of survival. Should a "restricted" rather than a "liberal" perioperative fluid regimen be employed? It is arguable that prevailing fluid therapy is not evidence-based. Recent observations suggest that restraint in fluid administration correlates with better outcome. The development of a protocol-based fluid optimization program may help minimize the risk of perioperative fluid overload.

Complicated diverticular disease of the colon, do we need to change the classical approach, a retrospective study of 110 patients in southeast England

BackgroundComplicated diverticular disease of the colon imposes a serious risk to patient's life, challenge to surgeons and has cost implications for health authority. The aim of this study is to evaluate the management outcome of complicated colonic diverticular disease in a district hospital and to explore the current strategies of treatment.MethodsThis is a retrospective study of all patients who were admitted to the surgical ward between May 2002 and November 2006 with a diagnosis of complicated diverticular disease. A proforma of patients' details, admission date, ITU admission, management outcomes and the follow up were recorded from the patients case notes and analyzed. The mean follow-up was 34 months (range 6–60 months)ResultsThe mean age of patients was 72.7 years (range 39–87 years). Thirty-one men (28.18 %) and Seventy-nine women (71.81%) were included in this study. Male: female ratio was 1:2.5.Sixty-eight percent of patients had one or more co-morbidities. Forty-one patients (37.27%) had two or more episodes of diverticulitis while 41.8% of them had no history of diverticular disease.Eighty-six percent of patients presented with acute abdominal pain while bleeding per rectum was the main presentation in 14%. Constipation and erratic bowel habit were the commonest chronic symptoms in patients with history of diverticular disease. Generalized tenderness was reported in 64.28% while 35.71% have left iliac fossa tenderness. Leukocytosis was reported in 58 patients (52.72%).The mean time from the admission until the start of operative intervention was 20.57 hours (range 4–96 hours). Perforation was confirmed in 59.52%. Mortality was 10.90%. Another 4 (3.63%) died during follow up for other reasons.ConclusionComplicated diverticular disease carries significant morbidity and mortality. These influenced by patient-related factors. Because of high mortality and morbidities, we suggest the need to target a specific group of patients for prophylactic resection.

Paediatric burns caused by other children

Children with burns inflicted by other children represent a small proportion of referrals to our paediatric burns unit. The aim of this paper is to investigate any differences between them. Prospective observational audit. Children admitted between January 1998 and December 2003. Forty-seven patients were admitted to our paediatric burns unit with burns inflicted by other children, of which 38 were male. Scalds were the cause of 53% of all the injuries. Two distinct groups were identified; one group had their burns inflicted by other children accidentally (Group A) and another reported their burns as inflicted by other children intentionally (Group B). The majority had less than 10% total body surface area (TBSA) burns sustained at home. Thirteen patients (27.7%) were reported as deliberate (Group B). The majority in Group B were males (90.9%, P>0.0001) with a median age of 12 years (P>0.0001) who sustained flame burns (P>0.0001) outdoors with a greater %TBSA (mean 12.1% versus 3.8% for Group A) and higher percentage of full thickness burns (38.5% versus 20.6% of group A). More children from Group B had separated parents (53.9% versus 5.9%) and came from poorer socioeconomic backgrounds (69.2% versus 8.8%). All the cases that required ITU admission came from this category. These patients required more surgery as compared to the accidental group (61.5% versus 26.4%). Children from Group B required prolonged periods of outpatient follow up (53.8% versus 14.7% from Group A) and a greater proportion of these children failed to keep outpatient follow-up appointments as compared to the accidental group (38.5% versus 23.5% of Group A, P=0.0007). Older male children sustained significant burns outside their homes. They reported them as being deliberate assaults, although on closer inspection of the circumstances it was difficult to support their account of the events.

Toxic shock syndrome responsive to steroids

BackgroundToxic Shock Syndrome is a dangerous disease with clinical features mimicking bacterial sepsis. The best management of Toxic Shock Syndrome is not determined.Case presentationA 28 year-old woman presenting with high fever, tachycardia and widespread erythroderma is described. She failed to respond to intravenous antibiotics and required ITU admission. High dose corticosteroids dramatically improved her clinical condition.ConclusionToxic Shock Syndrome should be considered in the differential diagnosis of unexplained fever, rash and features resembling septic shock. Corticosteroids should be considered in the treatment of Toxic Shock Syndrome.

Is Chronic Musculoskeletal Pain in Adulthood Related to Factors at Birth? A Population-Based Case-Control Study of Young Adults

Chronic musculoskeletal pain affects one-third of the general population, yet apart from occupational and psychosocial risk factors, relatively little is known about its aetiology. Exposures in very early life may influence the development of chronic pain as a young adult. However, unlike the study of early life influences on some other common chronic diseases, little research has been conducted in this area. Using a nested case-control analysis of a population-based cross-sectional survey, this pilot study investigated associations of selected birth-related factors with chronic pain in young adults living in North Staffordshire. 858 participants responded to the survey (adjusted response 37%). 580 were included in the case-control analysis. No association was found between prematurity (OR: 0.14 95% CI: 0.0, 1.1), foetal distress (OR: 0.80 95% CI: 0.4, 1.8), artificial commencement of labour (OR: 1.04 95% CI: 0.6, 1.8), or non-vaginal delivery (OR: 1.03 95% CI: 0.5, 2.0) and chronic pain at age 18-25 years. Associations were observed between pain status and low birth weight (OR: 2.17 95% CI: 0.6, 7.0) and neonatal ITU admission (OR: 1.63 95% CI: 0.4, 7.4). Although these estimates were not statistically significant in this exploratory study they may be worthy of further investigation.

A different look at biogeochemistry

<h3>Background</h3> The neurotrophic effects of Covid-19 are becoming increasingly recognized, with altered mental state now being the second most common presenting complaint insert numbers. A key question is whether this has long term consequences. Cognitive problems are commonly reported in patients 3 months after acute infection as part of the so called Long-Covid syndrome. However, the underlying cause is not well understood. Candidate explanations include legacy from encephalitis and stroke; however, other complications such as the sequelae, delirium, remain underexplored. Furthermore, little consideration has been given to functional cognitive disorders and the cognitive consequences of depression, anxiety and fatigue. <h3>Aims</h3> We propose a structured approach to clinical assessment for clinicians reviewing late cognitive complaints after COVID 19. <h3>Methods</h3> We created our own unique framework for neurocognitive Covid assessment based upon a review of the literature. <h3>Results</h3> Covid status- Any positive test. If not review of core symptoms such as breathlessness, headache, anosmia, nasal obstruction, cough, myalgia, or gustatory dysfunction; duration, extent of exposure to Covid confirmed cases. Consider rapid antibody testing. Neuropsychiatric history- Part 1 symptoms at onset- in particular disruptions of consciousness and altered mental state. Acute memory impairment, anterograde/retrograde and with/without a temporal gradient. neurocognitive function. ITU admission and oxygen requirements. Part 2 Current cognitive and mental state- in addition to standard history seek evidence of internal inconsistency of memory symptoms and attentional dysregulation. Has social cognition and meta-cognition been affected. Note attribution bias i.e. no Im not depressed, I cant enjoy anything because of my symptoms Background history- subtle suggestion of neurodegeneration and depression, anxiety and functional symptoms should be explored. MRI findings- signal changes in the medial temporal lobe, nonconfluent multifocal white matter hyperintense lesions, and isolated white matter microhemorrhages. Novel biomarkers IL-6, MCP-1, and IP-10. <h3>Conclusion</h3> Cognitive symptoms are common after confirmed and assumed COVID exposure. We propose a framework for neuropsychiatric assessment and the use of adjuvant imaging and potential biomarkers.

The management of acute severe asthma in adults

Asthma is a common condition, which can develop into a severe, life-threatening form in any sufferer. Generally, those at risk of an acute attack are women from minority ethnic groups, who have a poor compliance history. Most patients that die of asthma do so in the community. Those who attend the emergency room generally respond to conventional treatments and hospital admission. However, a small proportion of patients will require ITU admission and mechanical ventilation, and, if the admission is not secondary to cardiorespiratory arrest, generally survive. Ventilation techniques that prevent dynamic hyperinflation and the consequent complications of hypotension and barotrauma, are now generally adopted. This includes a pressure-limited mode of ventilation associated with low tidal volumes, high flows and low respiratory rate. Follow up of these patients is essential as they form a very poor prognostic group. Detailed self-management planning, PEFR monitoring and physician review should be therefore encouraged.