A logistic challenge - use of electromyographic endotracheal tube in an extremely narrowed airway

J. Jeyadoss, R. Lea, J. Horwoo

Cardiac pacing in patients with a cervical spinal cord injury

Study design: Retrospective medical record review. Objectives: To compare patients, admitted to an intensive care unit (ICU) with an acute cervical spinal cord injury (SCI) and documented motor deficit, who did, with those who did not, require a cardiac pacemaker. Setting: South Australian Tertiary Referral Intensive Care and Spinal Injury Unit. Methods: Retrospective medical record review and data set linkage. Results: From 1995 to 2007, 465 patients sustained a cervical SCI. Of these, 30 (6.5%) were admitted to ICU with a clinically assessable motor deficit and 3 (0.6% of all patients, or 10% of those admitted to ICU) required a cardiac pacemaker. All three patients had a cervical SCI, C5 (American Spinal Injury Association A) tetraplegia, and required invasive mechanical respiratory and inotropic support and a tracheostomy for weaning. Two patients (66%) were discharged alive to rehabilitation. Patients requiring a pacemaker had bradycardic episodes over a longer period (11 vs 4 days, P¼0.01), a trend towards a later onset of bradycardia (8 vs 1.5 days, P¼0.05) and a longer ICU length of stay (37 vs 10 days, P¼0.02). Conclusion: Patients with a cervical SCI requiring a cardiac pacemaker are characterized by a higher level of SCI injury and motor loss, require mechanical respiratory and inotropic support, a tracheostomy to wean, and bradycardic episodes of a later onset and over a longer period of time. These findings suggest that such patients should be managed at hospitals with specialized acute spinal injury, intensive care and cardiac pacemaker services.P Rangappa, J Jeyadoss, A Flabouris, JM Clark and R Marshal

Association between emergency department length of stay and outcome of patients admitted either to a ward, intensive care or high dependency unit

ObjectiveTo evaluate the association of ED length of stay (EDLOS) and outcome of patients admitted to a ward, intensive care (ICU) or stepdown (high dependency) unit (SDU).MethodsDesignRetrospective cohort study using linked administrative and clinical data.Setting650-bed, university-affiliated, tertiary referral hospital, whose ED has approximately 60 000 patient presentations per annum.ParticipantsAdult patients admitted via the ED, to a ward (ED to ward), ICU (ED to ICU) or SDU (ED to SDU), and whose EDLOS was Outcome measuresHospital outcome and LOS.ResultsA total of 43 484 patients over 4 years. Median EDLOS was 2:36 h for ICU, 5:07 h for SDU and 7:19 h for ward (P ConclusionsEDLOS was greater for ED to ward patients, and of the ED to ward patients who died. At an EDLOS of 4 h there were fewer ICU, in comparison with ward, patients remaining in the ED. Future studies that report on EDLOS should differentiate for patients admitted from the ED to the ward, ICU or SDU.Arthas Flabouris, Jellsingh Jeyadoss, John Field and Tom Soulsb

Direct and delayed admission to an intensive care or high dependency unit following discharge from the emergency department: associated patient characteristics and hospital outcomes

OBJECTIVE: To compare patients admitted from the emergency department (ED) directly to a ward (EDWard), the intensive care unit (EDICU) or stepdown (high dependency) unit (EDSDU) with patients admitted via the ED, but whose admission to an ICU (EDWardICU) or SDU (EDWardSDU) was preceded by a ward stay. DESIGN, SETTING AND PARTICIPANTS: Administrative and clinical data linkage; 650-bed, tertiary referral hospital, whose ED has about 60 000 patient presentations per annum; adult patients admitted via the ED to a ward, ICU or SDU and whose ED length of stay (LOS) was < 24 h. MAIN OUTCOME MEASURE: Hospital outcome and stay. Results: From January 2004 to December 2007, there were 43 484 patients, of whom 40 609 (93.4%) were EDWard, 1020 (2.3%) were EDICU, 873 (2.0%) were EDSDU, 503 (1.2%) were EDWardSDU, and 479 (1.1%) were EDWardICU. Hospital mortality for EDWardICU patients exceeded that of EDICU patients (34.9% v 23.3%; P < 0.01), as did EDWardSDU exceed EDSDU (12.3% v 7.8%; P < 0.01). Median ward stay for EDWardICU patients was 47 h 37min (IQR, 14 h 48min – 131 h 53min) and for EDWardSDU patients, 46 h 18min (IQR, 18h 28 min – 140h 12 min) (P=0.75). Compared with patients admitted to the ICU from the operating theatre, EDWardICU patients had a longer median ward stay (58 h 35min v 34 h 36min; P = 0.03) and hospital mortality (42.8% v 20.2%; P < 0.01). CONCLUSION: Patients discharged from the ED to a general ward and subsequently to an ICU or SDU had a mortality that exceeded that of ED patients admitted directly to the ICU or SDU. Further investigations are warranted to explain this excess mortality and ascertain the extent of potential preventability.Arthas Flabouris, Jellsingh Jeyadoss, John Field and Tom Soulsbyhttp://www.ncbi.nlm.nih.gov/pubmed/2296321

The effect of sevoflurane on the transmural dispersion of repolarisation in patients with type 2 diabetes mellitus: a prospective observational study

The 'torsadogenic' property of a drug is linked to its ability to increase the transmural dispersion of repolarisation, represented by the interval between the peak of, and the end of, the T-wave (Tp-e interval) in an electrocardiogram. Reports have consistently shown that sevoflurane does not increase the Tp-e interval. Type 2 diabetes is a risk factor for increased QTc (rate-corrected QT interval), QTcd (rate-corrected QTc dispersion: difference between the maximum and the minimum QTc interval), and Tp-e, as well as the rate-corrected Tp-e (Tp-e/QTc ratio). The study aimed to ascertain whether sevoflurane increased the Tp-e interval and Tp-e/QTc ratio in patients with diabetes, thereby increasing their risk of torsades. We enrolled 35 female patients; 17 with type 2 diabetes and 18 controls undergoing non-laparoscopic surgery under sevoflurane anaesthesia. The Tp-e interval, Tp-e/QTc ratio, QTc and QTcd were recorded after intubation, 5, 10, 30 and 60 minutes into the anaesthetic, and were compared between the groups. No significant increase in the Tp-e interval or Tp-e/QTc was observed between or within the groups (a 13 ms increase was considered significant). In the control group, the QTc was significantly increased from baseline immediately after intubation (449 versus 414 ms, P <0.001); at 5 minutes (434 versus 414 ms, P=0.01); at 10 minutes (444 versus 414 ms, P=0.002); at 30 minutes (439 versus 414 ms, P=0.001) and at 60 minutes (442 versus 414 ms; P <0.001) (a 20 ms increase was considered significant). No significant increase in QTc was observed in the diabetic group. There were no between or within group differences observed for QTcd. Our findings suggest that sevoflurane does not have a significant predictable pro-arrhythmic effect in type 2 diabetic patients in the absence of other factors affecting ventricular repolarisation

Cardiac pacing in patients with a cervical spinal cord injury

Study design: Retrospective medical record review. Objectives: To compare patients, admitted to an intensive care unit (ICU) with an acute cervical spinal cord injury (SCI) and documented motor deficit, who did, with those who did not, require a cardiac pacemaker. Setting: South Australian Tertiary Referral Intensive Care and Spinal Injury Unit. Methods: Retrospective medical record review and data set linkage. Results: From 1995 to 2007, 465 patients sustained a cervical SCI. Of these, 30 (6.5%) were admitted to ICU with a clinically assessable motor deficit and 3 (0.6% of all patients, or 10% of those admitted to ICU) required a cardiac pacemaker. All three patients had a cervical SCI, C5 (American Spinal Injury Association A) tetraplegia, and required invasive mechanical respiratory and inotropic support and a tracheostomy for weaning. Two patients (66%) were discharged alive to rehabilitation. Patients requiring a pacemaker had bradycardic episodes over a longer period (11 vs 4 days, P¼0.01), a trend towards a later onset of bradycardia (8 vs 1.5 days, P¼0.05) and a longer ICU length of stay (37 vs 10 days, P¼0.02). Conclusion: Patients with a cervical SCI requiring a cardiac pacemaker are characterized by a higher level of SCI injury and motor loss, require mechanical respiratory and inotropic support, a tracheostomy to wean, and bradycardic episodes of a later onset and over a longer period of time. These findings suggest that such patients should be managed at hospitals with specialized acute spinal injury, intensive care and cardiac pacemaker services.P Rangappa, J Jeyadoss, A Flabouris, JM Clark and R Marshal