This position statement from the Neurocritical Care Society advises on what to do when faced with a patient with a devastating brain injury (in practical terms it relates to those patients for whom neurosurgery is not carried out). The gist is that early prognostication is not the right thing to do and that such patients should be admitted to an ICU (not necessarily a neuro-ICU) and reassessed over a period of up to 3 days. The rationale is that early prognostication is unreliable (this review gives some background) and that by withdrawing life sustaining treatment we would be denying a real chance of life with full neurological recovery.
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Neisseria Meningitidis (the Meningococcus) has 13 serogroups, with A, B, C and W being the most common. I must admit I’d never heard of ‘Meningitis W’ before, but as you’ll read it’s a rare disease to be aware of.
Healthcare is a high risk and complex environment, and discussion of risk is emotive (take, for example, the headline chosen by the Times to put above a story making some effort to explain a fair blame approach).
In trying to make sense of this this complex difficult and uncomfortable area however, one of the first steps must be to quantify and describe the risk. Unplanned admissions to critical care would seem a reasonable place to look; sampling such cases for review is an accepted method that in an ideal world all critical care units would do in co-operation with the rest of the hospital. This has to be in the running for the best title of a presented abstract “Ambitious but hopeless Anaesthesiologist: Case Study” (it’s abstract no 59 if you’re interested). In it, the somewhat angry authors describe a colleague (for whom there appears to be little respect) attempting to insert a haemodialysis catheter into the subclavian vein.
During my training I think I’ve been steered to think of 0.9% saline as akin to the devil, causing hyperchloraemic acidosis in all it touches – is that true?
As far as complications go, anastomotic leak after emergency bowel surgery is not to be recommended. The early identification of a leak is crucial. C-Reactive Protein (CRP) has been suggested as a marker that may be useful to identifying this complication, but the question is whether it is useful in the case of the high risk emergency laparotomy in the critical care environment.
The ageing population is apparently one of the reasons the NHS is ‘under pressure’. This paper looks at the impact of the elderly on ICU demand in the Netherlands.
I picked up this paper as a local news story rather than because of its content - it was written by our local neurosurgical research group. Turns out it was very interesting, but not for the reasons I thought it might be..
One of our nurses always asks me for a Nicotine patch if she’s looking after a smoker. We always have the same discussion; how the 20ml/hr of Propofol is making it unnecessary and how Nicotine patches increase mortality. In reply she always tells me we wouldn’t need 20ml/hr Propofol if I treated the Nicotine withdrawal, and to stop being so awkward, uncaring and obnoxious (the last bit is implied by the ‘look’!). To try and reassure myself I’ve dug out the paper on which I base my mortality claim. It can be found here.
Whether all critically ill patients need the routine administration of stress ulcer prophylaxis (SUP) has been controversial for over 20 years. Much of the evidence both for and against is of poor quality, and is pretty old.
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