critical care 2013

ISSUE 02

pregnancy in hiv positive woman poses challenges for icu

A

s HIV has become a chronic, stable condition, more HIV positive women are falling pregnant. This in turn poses many challenges for ICU practitioners, such as the safe management of the pregnancy; decreasing the risk of mother to child transmission and the risk of rapid progression of the disease during pregnancy.

This was the topic explored by Dr Sean Chetty from the University of the Witwatersrand and head of anesthesiology at Rahima Moosa Mother and Child Hospital in Johannesburg at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine in Durban.

“The HIV/AIDS epidemic intersects with the problem of maternal mortality in many circumstances. Almost half the global HIV positive population are women in their reproductive years,” Chetty said.

“Across the world, over two million HIVinfected women are pregnant each year, over 90% of them in developing countries.In addition, close to 600,000 women die each year from complications of pregnancy and childbirth.”

Chetty said the contribution of HIV/AIDS to maternal mortality was difficult to quantify, as the HIV status of many pregnant women was not always known. This was due to poor access to HIV counseling and testing in many countries where infection rates in pregnant women ranged widely from below 1% to over 40% .

“The highest rates are still in Africa, although prevalence in some Asian countries has risen considerably,” Chetty said.

He said women living with HIV/AIDS might be more susceptible to obstetric causes of maternal mortality, such as post-partum haemorrhage, puerperal sepsis and complications of caesarean section.

“There is growing evidence for the impact of the AIDS epidemic on maternal mortality rates and for the effect of AIDS-related complications on maternal deaths,” Chetty said.

According to an article published in The Lancet in May 2013 HIV-infected pregnant or post-partum women had around eight times higher mortality than uninfected women. On the basis of this estimate, the authors predicted that roughly 24% of deaths in pregnant or post-partum women were due to HIV in

By LYSE COMINS sub-Saharan Africa. The authors suggested that safe motherhood programmes should pay special attention to the needs of HIV-infected pregnant or post-partum women.

“Obstetric causes of maternal morbidity and mortality may be more severe in women infected with HIV, and they may be more susceptible to infectious and post-surgical complications,” Chetty said.

These include higher reported rates of ectopic pregnancy, early abortion, bacterial pneumonia, urinary tract infection, oral and recurrent vaginal thrush and other infections.

Chetty said malaria and tuberculosis had become major complicating conditions in HIVinfected pregnant women, while anaemia may be more frequent and severe in HIV-infected women, especially where pregnancy was complicated by malaria.

“Post-partum haemorrhage has been described as more common in some studies, and may be more serious if associated with pre-existing anaemia in HIV-infected women,” Chetty said.

Chetty said HIV patients in ICU fell into three groups: • AIDS related opportunistic infections; • Immune reconstituted patients who need ICU care for non-HIV related conditions; Such as post surgery, trauma. Challenges in this group are related to ARV management regarding toxicity and interactions with ICU drugs; and • Non-infectious complications of HIV including accelerated atherosclerosis, neurocognitive disorders and solid organ tumours.

“When patients infected with HIV are admitted to the ICU with respirator compromise or failure, the strategic management approach is not dramatically different from the management in HIV-uninfected patients,” Chetty said.

While HIV related syndromes could masquerade as sepsis, he said the management of sepsis for patients with HIV infection should not differ from principles followed for uninfected patients.

Chetty said liver disease was the leading cause of death in some recent studies of patients

infected with HIV (2006 Weber, 2010 Smith).

“Chronic viral hepatitis is a common coinfection in these patients, and is an important cause of liver related morbidity and mortality in this patient population,” Chetty said.

“Alcohol use is frequent in this population and also contributes to liver-related mortality.”

He said this problem was greatest in the Western Cape and Northern Cape, in the South African context.

“Although previous studies suggest that the prolonged exposure to ARVs increases the risk of liver-related deaths, a 2012 report suggests that liver-related death caused by ART-related toxicities in HIV mono-infected patients is rare.”

Chetty said it was important to be able to prognosticate the outcome of pregnant patients admitted to ICU irrespective of the HIV status.

“A 2011 study co-authored by Professor Fathima Farouk, from Johannesburg, evaluated the appropriateness of using the APACHE 2 and SAPS 2 scoring systems for obstetric patients admitted to the ICU. “The authors concluded that both scoring systems are good discriminators of illness severity and may be valuable for comparing obstetric cohorts but the APACHE2 significantly overestimates mortality in this group of patients.”

Ultimately, HIV positive pregnant patients in ICU should be managed with the same vigour that all our patients are managed, with the proviso that these patients will generally also have challenges that must be individually addressed.

Dr Sean Chetty

COLUMBIA’s EDUCATION CAMPAIGN LOWERS MATERNAL MORTALITY C

olumbian critical care experts have dramatically improved the country’s maternal mortality rate by using rapid response teams to drive a campaign focused on reducing admission time to ICU and educating nursing staff, doctors and midwives on the main causes of death.

Jose Antonio Suarez, ICU director and associate professor of obstetric critical care at the University of Cartegena in Columbia said his team had conducted a surveillance study and was shocked to discover the high rate of “near miss” events where pregnant women almost died in ICU across the country.

These “near misses” were situations where maternal patients presented with main diseases - like pre-eclampsia, organ dysfunction and organ failure.

“We started a pilot study including 365 hospitals across the country. We found more than 4600 near miss cases. The fact is that we got a big surprise that almost 50% of those patients were in ICU settings so we have a high ICU admission of obstetric patients in our country that we did not even know about before,” Suarez said.

However, Suarez said it was not enough to merely report on near misses so the team, working with local municipalities, public health and the ministry of health, embarked upon an analysis of every maternal patient admitted to ICU.

By LYSE COMINS The study found four major reasons for delays in maternal patients seeking health care. These included: • A poor understanding of risk factors and complications during pregnancy; • Poor previous experience of health care, or cultural beliefs, or long distances to health centres and hospitals; • Inadequate referral systems or health care coverage; and • Inadequately trained and poorly motivated medical staff or poor facilities and lack of medical supplies.

Suarez said almost 50 percent of the cases analysed had long delays, which indicated the need for a call to action.

“The first step was to go out to the delivery room, to the wards and to emergency departments to work together with the other departments,” Suarez said. “We chose the biggest maternal hospital in Columbia with around 10 000 deliveries per year and we saw that the time between emergency department admission and admission to ICU was directly related to the probability of organ dysfunction.”

Suarez said the time was shortened in a two year period and severe morbidity dropped.

“This allowed us to launch the first consensus document (a few weeks ago) about criteria of admission of obstetric patients. We are so proud of this because

Jose Antonio Suarez

for more than ten years we have not had real consensus of when a sick pregnant patient should be transferred to an ICU facility,” Suarez said.

Suarez said the team had embarked on a national education policy to educate health care workers at all levels, including traditional midwives, about the major causes of maternal mortality in Columbia, namely hypertensive disorders, obstetric haemmorage and obstetric and nonobstetric sepsis.

“We started not only with lectures and conferences. We focused on areas with the highest mortality and travelled around the country to train the people who take care of the patients at low level facilities,” Suarez said.

The result was a drop in maternal mortality from 88,8 to 69,5 per 100 000 live births. This is a marked contrast to South Africa where the mortality rate is more than 300 per 100 000 live births, in spite of the comparatively strong economy of the country.

ICU design - a healing environment for all A

well-designed ICU can almost be regarded as third person in the way we treat patients, said Dr Lliam Brannigan of South Africa, a specialist in ICU design. It should create a nurturing environment for all health-care staff.

In a lively presentation delivered at the 11th Annual Congress of the World Federation of Societies of Intensive and Critical Care Medicine, currently underway in Durban, Brannigan told the audience that health care consumers are getting more demanding, people are more educated and will ask more from the medical system.

They are more likely to insist on having a role in the decision-making process regarding treatment and to include their families in those decisions.

“The goal of ICU design is therefore to increase the involvement of family in patient well-being and healing,” he said.

“There is also an increasing need for multidisciplinary teams to have a say in ICU design.”

According to Brannigan, there are four areas of design: the patient support zone, the clinical support zone, the staff support zone and the family support zone.

The patient support zone is the room where the patient is treated, and factors in design include the amount of space, single versus multiple rooms, isolated versus open rooms and access to medical utilities.

By NIKKI MOORE The clinical support zone is where the nurses do a lot of their work, and these include the procedure areas, the laboratory and pharmaceutical services, imaging and diagnostics, and the multi-disciplinary access and assistance.

The unit support zone is the area where staff should feel ‘safe’, where staff can relax and rest without feeling pressured.

“These include personal rooms, ablution and sleeping facilities, conference and academic facilities and unit administrative space. It’s vitally important that these are separated from the patient area of the unit.”

“The greatest advances in ICU design have been in the family support zone, in the incorporation of the family in the patient’s treatment,” said Brannigan What is vitally important here is patient access for families, a cafeteria, places to shower and sleep, a multi-faith area for meditation and prayer, and a private area for family counselling - especially to break bad news.

Trends in modern ICU design, according to Brannigan, are an increase in floor space, more room for family to visit, and ‘pods’ of 8 - 12 single-bed rooms. This is accompanied by a move away from centralised nursing stations to decentralised nursing with wireless monitoring stations.

Dr Lliam Brannigan

ICUs are becoming more flexible in design because of changing circumstances, as well as an anticipation that circumstances will change even more in the future.

In response to a question from the floor, which complained that ICU rooms never have enough plug points, Brannigan commented that the trend was moving away from headboards and wall-mounted plugs, and more towards central columns and rotating booms. These prevent wires from trailing over the floor.

ICU IN the first world and the third world A

n intensivist from Chris Hani Baragwanath hospital, Busi Mrara, recently returned from a year-long visit to the Royal Brisbane hospital in Australia, and shared her experiences of a ‘firstworld’ hospital as compared to a ‘thirdworld’ hospital. She was speaking at the 11th Annual Congress of the World Federation of Societies of Intensive and Critical Care Medicine, currently underway in Durban.

Busi Mrara

By NIKKI MOORE “The Royal Brisbane has 1 000 beds to serve a population of 3 million residents,” she began, “in comparison with Baragwanath, which has more than 3 000 beds and serves the Soweto population of 6 million. The way you evaluate the effectiveness of your care is through survival rates, re-admissions, medical errors, resource consumption and cost-effectiveness.”

While the Royal Brisbane has roughly the same staff-to-patient ratio as Baragwanath, Mrara commented on the difference in support services, resources and competence of the nursing staff.

While the Royal Brisbane had 26 ICU beds, Baragwanath only has 16.

“This means that we triage strictly, as there is little access to ICU at Bara,” she said.

Australia, with its higher standard of living, ageing population and contrasts in income and literacy, spends 8% of its GDP on health, while South Africa spends 12,5% of its GDP. “Australian nurses are better trained, they are more involved and have higher job satisfaction, with a consistent bedside presence and better maintenance of standards.” she said.

Dr CC Igboamali is a Doctor in the casualty department at Robs Ferreira Nelspruit hospital. He said he came to the conference to find out the basics of ICU care.

“Baragwanath does not have enough physiotherapists, or social workers. Australia has in-house pharmacists, and no shortage of orderlies. They have ICU outreach with multidisciplinary emergency response teams and telephone links with remote hospitals.”

“Do we need to breach this gap?” Mrara asked. The answer seems to be ‘yes,’ as the Australian hospital has a mortality rate of 6% - one of the lowest in the world, whereas Baragwanath has a mortality rate of 31%.

There is also a high rate of re-admissions, medical errors, and the economic outcomes are not good. Baragwanath does, however, retain its nurses longer than the Royal Brisbane!

“Can we bridge the gap?” asks Busi again. With regard to resources, the answer is ‘no’. For staffing the answer is ‘yes’. For ICU outreach, the answer is ‘partly’.

“We are busy with a nation-wide audit of ICUs,” concludes Mrara, “and there are planned expansion and university initiatives. It is all designed to give hospitals greater autonomy.

Sending hospital staff overseas to see how other countries run their ICUs is helpful in the short term - they can immerse themselves in the different ways of doing things, but they must also be able to understand how this will work in their own environment.”

Dr Hou Xiaotong is from China and said that he attended the critical care conference to get more knowledge about ICU, meet new people and to see South Africa.

Itumeleng Masike from South Africa is a dietician at the Jubilee Hospital in Gauteng. She said that she attended the critical care conference to build on the knowledge that she already has and to learn more about critical care and nutrition.

Mrs Rajeshree Dhanilal of South Africa is a critical care nurse at the R.K.Khan hospital in Durban. She said that she was awarded a sponsorship to attend the congress and she found it to be inspiring.

Call for sepsis data from lower resourced countries G

eneral strategies to fight sepsis in resource poor settings could well be completely different from those applied in wealthier countries. Instead, interventions and treatment should be tailor made to the needs of lower income countries, taking into account that the human capacity and infrastructure required for implementation may not exist.

Dr Satish Bhagwanjee, director of the Critical Care Training Program in the Department of Anesthesiology at the University of Washington Medical Center in Seattle and co-chair of the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine, told delegates that there was an urgent need for adequate data from poorer regions. There is also a need to develop human capacity and infrastructure to deal with sepsis which was a significant contributor to both adult and child mortality.

“If we don’t take steps to manage this, then we’re not going to get very far. If we don’t know what’s going on we’re going to struggle to make any progress whatsoever,” he warned.

Overall, Bhagwanjee said, there was a “lot of fluffiness in Dr Satish Bhagwanjee what we know.”

By SHIRLEY LE GUERN He said it helped to get a bigger picture. Although there is global variability in life expectancy, in general in Africa and South East Asia, life expectancy was significantly less than other parts of the world. When disproportionate spending on healthcare was considered, he said it was not surprising that life expectancy was low and that this would have an inevitable impact on critical care.

He said that when one considered data from resource rich regions such as Europe, it was evident that sepsis was a problem and a major contributor to mortality. However, there was significant variability in treatment and resources which was problematic. In the United States, the pattern was similar. However, what was profoundly different was the much higher expenditure on both health and sepsis care when compared to any other country.

Returning to the lack of research into what is actually happening in poorly resourced countries, Bhagwanjee said that limited data painted a scary picture. For example, in South Africa, a middle income rather than a lower income country, the antibiotic treatment given for sepsis was only appropriate in 42 percent of cases and there was little modification of treatment once laboratory results came back.

The other side of the coin, however, was the problem of massive over diagnosis due to a lack of expertise on the part of physicians with no or limited ICU experience or competing interests which saw them having to work in other areas.

However, he conceded that lack of knowledge which delayed both diagnosis and treatment of sepsis was also rife in the United Kingdom and America despite better resources.

LIGHTNING STRIKES NEED NOT BE FATAL G

lobally, lightning causes more deaths than any other natural event or phenomenon, claiming as many as 24 000 lives every year.

However, the majority of people who are hit by lightning, an estimated 240 000, survive the lightning strike and go on to live full lives although they faced with permanent side-effects such as seizures and tinnitus (ringing in the ears).

These interesting facts and the medical intervention needed by lightning strike survivors were shared by Professor Roger Dickerson, specialist emergency physician and intensivist and vice-president of the Emergency Medicine Society of South Africa at the 11th Congress of the World Federation of Societies of Intensive and Critical Care Medicine currently underway in Durban.

“Lightning causes neurological damage and is not usually fatal unless it stops the heart when it strikes,” Dickerson said.

“If we look at some of the literature that has been published, about 2000 thunderstorms occur worldwide at any point in time and there are about eight million grounds strikes across the globe.”

Dickerson said the survival rate of patients was high and proper management would produce positive results. However, he added that the SA Weather Service data revealed “quite a scary” picture of the high density of lightning strikes on the Highveld and the Escarpment.

He said studies had shown that men were five times more likely to be killed by lightning than women and the reason given was that men tend to be outside more for work and engaged in a higher level of risk taking behaviours.

“With regards to mortality and morbidity, the modern literature demonstrates that there is nothing related to age or gender or the fact of whether you are struck on the trunk or arms.

However, if you have lower burns (on the legs) and head burns or immediate cardiac arrest at

By LYSE COMINS the time of the strike these are predictors of a high mortality,” Dickerson said.

Dickerson said a lightning strike, although classified as a non-thermal burn was not an electrical burn.

“Primarily, a lightening strike is a neurological injury it has an effect on the brain and on the ergonomic nervous system and on the peripheral nervous system,” Dickerson said.

He added that survivors presented with neurocognitive behaviour changes and seizures.

“The good news is that most patients do regain consciousness quite rapidly following the strike and most are able to be discharged home from an emergency department.”

About 60 percent of survivors have lightening induced paralysis, which usually recovered spontaneously although it could last for up to two weeks.

Dickerson said patients arrived in the emergency ward confused and hypotensive due to the lightening strike’s interference with the autonomic nervous system. They would have the distinctive branching scarring known as Lichtenberg figures.

“The most important thing about the lightning strike is that you do not treat it like you would treat another burn. We do not remove the dead tissue unless it is very clearly indicated and we don’t do it from an early period point of view,” Dickerson said.

“Our resuscitation is based on a needs basis. We look at the patients as being exposed to massive amounts of trauma. We need to ensure they do not have associated injuries like long bone fractures or spinal injuries and then we take care of what the lightning strikes actually do,” Dickerson said.

“We need to take care of these patients with regards to seizures. If they are presenting with chest pain we need to investigate further.

Perhaps the big focus should be on urine analysis and plasma analysis for myoglobin.”

He added that it was also important to do an ECG as patients presented with prolonged QT intervals, a risk factor for sudden death, for up to a year.

“The important thing is that it tends to be normal within the first 24 to 48 hours so it is necessary to repeat the ECG at a later stage,” Dickerson said.

He said if the patient was unconscious it was necessary to perform scans although this was debatable in other cases.

Dickerson added that appropriate ear care was also vital since the majority of patients would have ruptured the tympanic membrane that could heal or be surgically repaired.

“Most patients will survive to live very full and complete lives except that they will exposed to the life-long tinnitus and the possibility of seizures that can present throughout their lives. We need to always remember that these are not burn patients, although they are classified as burn patients,” Dickerson said.

Lichtenberg figures

This newsletter was produced by the team at HIPPO. www.hippocommunications.com