The pharmacokinetics of once-daily dosing of ceftriaxone in critically ill patients

The aim of this study was to determine the pharmacokinetic profile of the normal recommended dose of ceftriaxone in critically ill patients and to establish whether the current daily dosing recommendation maintains plasma concentrations adequate for antibacterial efficacy. Ceftriaxone at a recommended dose of 2 g iv was administered od to 12 critically ill patients with severe sepsis and normal serum creatinine concentrations. Blood samples were taken at predetermined intervals over the first 24 h and on day 3 for measurement of ceftriaxone concentrations. There was wide variability in drug disposition, explained by the presence of variable renal function and identified by the measurement of creatinine clearance. In nine patients with normal renal function, there was a high level of creatinine clearance(mean +/- S.D., 41 +/- 12 mL/min) and volume of distribution (20 +/- 3.3 L), which resulted in an elimination half-life of 6.4 +/- 1.1 h. In comparison with normal subjects, ceftriaxone clearance was increased 100%, volume of distribution increased 90% and the elimination half-life was similar. Three patients had substantially suboptimal plasma ceftriaxone concentrations. We confirm previous findings that ceftriaxone clearance in critically ill patients correlates with renal clearance by glomerular filtration. The elimination half-life is prolonged (21.4 +/- 9.8 h) in critically ill patients with renal failure when compared with previously published data in non-critically ill patients with renal failure. We conclude that in critically ill patients with normal renal function, inadequate plasma concentrations may result following od bolus dosing of ceftriaxone. Drug accumulation may occur in critically ill patients with renal failure.

Cohesion among nurses: a comparison of bedside vs. charge nurses' perceptions in Australian hospitals

Aim. This study examines the extent to which hospital nurses view their working environment in a positive sense, working as a cohesive group. Background. Despite the fact that nursing in Australia is now considered a profession, it has been claimed that nurses are an oppressed group who use horizontal violence, bullying and aggression in their interactions with one and other. Methods. After ethical approval, a random sample of 666 nurses working directly with patients and all 333 critical care nurses employed in three large tertiary Australian hospitals were invited to participate in the study in the late 1990s. A mailed survey examined the perceptions of interaction nurses had with each other. The hypothesis, that level of employment (either Level I bedside nurses or Level II/III clinical leaders) and area of work (either critical care or noncritical care) would influence perceptions of cohesion, as measured by the cohesion amongst nurses scale (CANS) was tested. Results. In total 555 (56%) surveys were returned. Of these, 413 were returned by Level I and 142 by Level II/III nurses. Of this sample, 189 were critical care and 355 noncritical care nurses. There was no difference between Level I and II/III nurses in mean CANS scores. It is interesting to note that the item rated most positively was, 'nurses on the units worked well together', however, the item rated least positive was 'staff can be really bitchy towards each other' for both Level I and II/III nurses. There was no difference in CANS scores between critical care and noncritical care nurses. Conclusions. Nurses working in Australian hospitals perceived themselves to be moderately cohesive but, as would be expected in other work settings, some negative perceptions existed.

Surgical outcomes of a randomized prospective trial involving patients with a proximal femoral fracture

Background: An orthopaedic management/patient-focused care unit (OMPFCU) involving a dedicated orthopaedic-geriatrics liaison team was established at the Royal Brisbane Hospital in 1994 in an effort to safely accelerate rehabilitation of patients with proximal femoral fractures. Methods: The surgical outcomes of the patients were monitored in order to determine whether accelerated rehabilitation had any significant adverse effects on the surgical outcomes, measured by mortality, readmission to hospital, deep wound infection, fracture union delay, mobility and the revision surgery rate. Results: No significant difference was recorded in mortality and morbidity, deep wound infection and revision surgery rates between patients in the Royal Brisbane Hospital OMPFCU and those in standard care in the orthopaedic surgery wards. Conclusion: Accelerated rehabilitation for patients with a proximal femoral fracture in a major teaching hospital can be accomplished safely.

Child-Pugh class, nutritional indicators and early liver transplant outcomes

Background/Aims: Patients with chronic liver disease undergoing liver transplantation have reduced body fat and muscle mass. The extent to which nutritional indicators and Child-Pugh class are predictive of postoperative outcome in adults is unclear. The aims of this study were to determine in adult patients undergoing transplant 1) the influence of preoperative Child-Pugh class and nutritional indicators on early transplant outcomes and one-year survival, 2) the relationship between nutritional indicators and Child-Pugh class and disease type. This study included 80 patients (1990-1994). Methodology: The nutritional indicators utilized were grip strength, triceps skinfold thickness and uncorrected mid-arm muscle area. Measured outcomes were ventilator time, intensive care stay, postoperative hospital stay and one-year survival. Results: Early morbidity was determined in survivors. Child-Pugh class C patients required longer ventilation and spent more time in the intensive care unit than Child-Pugh classes A and B. No significant relationships were found length of hospital stay. Relationships between the nutritional indicators (when controlled for Child-Pugh class) and early morbidity could not be determined due;to insufficient data. No relationship was established between one-year survival and Child-Pugh class or the nutritional indicators. Grip strength and mid-arm muscle area were lower in the patients in Child-Pugh:classes B and C. Parenchymal liver disease was associated with lower grip strength and mid-arm muscle area when compared to cholestatic disease. Conclusions: Child-Pugh class C is associated with greater early postoperative morbidity. Advanced Child-Pugh class is also associated with diminished muscle status and parenchymal disease.

Transient mesenteric ischaemic episodes tracked by continuous jejunal PCO2 monitoring during liquid feeding

Objective: To test the effect of liquid feeds on the responses to splanchnic ischaemia of a continuous rapid response PCO2 sensor inserted in the jejunum. Design: Prospective experimental animal study in a university research laboratory. Subjects: Adult male Wistar rats. Interventions: Adult male Wistar rats (285-425 g) were anaethetised with sodium pentobarbitone 60 mg/ kg i.p. and ventilated with 100 % oxygen and isoflurane via tracheostomy to a PaCO2 of 30-40 mmHg. A sensor was inserted into the mid-jejunum to record PCO2 every second. Distal aortic pressure was transduced. Four control rats received no feeds whilst in another four rats liquid feed was infused into the proximal jejunum at 3 ml/h. In each rat five episodes of splanchnic ischaemia were induced by 2-min elevations of an aortic sling to a mean distal aortic pressure of 30 mmHg. Measurements and main results: PCO2 elevations were always detectable, usually less than a minute from the onset of splanchnic ischaemia in both fed and unfed rats, with no difference in mean times to detectable response. In the fed rats there was a small but significant increase in the time to peak sensor response (196 +/- 16 vs. 180 +/- 12 s) and a trend towards an elevated mean baseline luminal PCO2 (67 +/- 9 vs. 55 +/- 4 mmHg). Conclusions: Brief episodes of splanchnic ischaemia were tracked successfully by a rapid response jejunal continuous PCO2 sensor during the infusion of a proprietary liquid feed preparation despite minor changes in PCO2 response characteristics and a possible elevation in baseline luminal PCO2.

Motorcycle exhaust burns in children

Objectives: To document and describe motorbike exhaust burns on children. Design, Patients and Setting: Departmental database and case note review of all children with motorbike exhaust burns seen at the Stuart Pegg Paediatric Burns Centre, Brisbane between January 1996 and October 2001. Main outcome measures: Number and age of children burned, circumstances of the injury, burns sustained, treatment required and long-term sequelae. Results: Twenty-four children, median age 8 years, sustained thermal burns, most commonly to the right lower leg. Thirteen children required surgery, and 17 required chronic scar management. Conclusions: We have identified motorbike exhausts as a cause of burns in children. The injuries received resulted in significant morbidity to these children and warrants a campaign airned at reducing the incidence of such injuries. (C) 2002 Published by Elsevier Science Ltd. and ISBI.

Increase in prevalence of nosocomial non-Candida albicans candidaemia and the association of Candida krusei with fluconazole use

Candida is an important nosocomial pathogen. This study was undertaken to provide information on the rate of candidaemia, to define the risks for candidaemia and to describe and account for the epidemiology of candidaemia at our institution between 1992 and 1999. The overall rate was 0.052 per 1000 patient days and 0.27 per 1000 discharges. The major risks for candidaemia were colonization at a non-sterile site (OR 3.85, 95%CI 1.80-9.09), total parenteral nutrition (TPN) in the absence of neutropenia (OR 11.8, 95%CI 4.5-35.4, P

Attitudes of paediatric medical ward staff to a dog visitation programme

No previous studies regarding either structured, strictly controlled pet visitation programmes in paediatric hospital wards or hospital staff attitudes towards them have been conducted in Australia. Information regarding these is essential in order to minimize problems during implementation of such programmes. The aim of the study was to analyse hospital staff perceptions regarding the introduction of a pet visitation programme in an acute paediatric medical ward prior to and following implementation of the programme and to compare attitudes between the various professional groups. The study consisted of two cross-sectional surveys. A total of 224 anonymous questionnaires were distributed to administrators, doctors, nursing staff and therapists 6 weeks before and 195 were distributed 12 weeks after the introduction of a pet visitation programme. Responses were received from 115 respondents (before the programme introduction) and 45 respondents (after the programme introduction). Prior to the introduction of the dog visitation programme, there were high staff expectations that the programme would distract children from their illness, relax children and that it was a worthwhile project for the hospital to undertake. Following implementation of the programme these expectations were strongly endorsed, in addition to the perception that the ward was a happier place, the work environment was more interesting and that nurses accepted the dogs. After implementation staff were less concerned about the possibility of dog bites and dogs doing damage to equipment. Allied health staff and non-clinical staff were more positive about the programme with respect to ward climate and acceptance than were doctors and nurses. We conclude that well-planned dog visitation programmes result in positive anticipation among staff and high levels of satisfaction following programme impact.

Ventilatory effects of neurophysiological facilitation and passive movement in patients with neurological injury

Thirteen intubated, high dependency patients with neurological injuries were studied in order to investigate the short term respiratory effects of neurophysiological facilitation and passive movement on tidal volume (V-T), minute ventilation (V-E), respiratory rate (V-R) and oxygen saturation (SpO(2)). The subjects were studied under four conditions: no intervention (control) and during periods of neurophysiological facilitation, passive movement and sensory stimulation. All periods were standardised to three minutes duration and all parameters were recorded before and after each intervention. Neurophysiological facilitation produced significant increases (p < 0.01) in V-E and SpO(2) (p < 0.05) when compared with control values, with an overall mean increase in V-E of 14.6%. Similarly, passive movement increased V-E (p < 0.01) by an average of 9.8% and also increased SpO(2) (p < 0.01). In contrast, sensory stimulation produced significant increases (p < 0.01) in SpO(2) with control levels, with no significant change in V-T or V-E. There was no significant difference in V-R with all treatments. This study provides preliminary evidence of improved short term ventilatory function following neurophysiological facilitation, independent of generalised sensory stimulation, which has not been previously examined in the literature, supporting its use in the management of high dependency neurological patients.

The use of ACE-inhibitors after myocardial infarction

Background: There is good evidence that angiotensin-converting enzyme (ACE) inhibitors are beneficial after myocardial infarction (MI). However, it is not known how widely this evidence is used in practice and whether all eligible patients receive this therapy. Aim: To assess the usage of ACE inhibitors in patients after MI in a large teaching hospital. Method: A one month prospective analysis, combined with a three month retrospective analysis, was conducted at the Royal Brisbane Hospital (RBH) in February-March 2000. Patients admitted with an MI or who had been diagnosed with an MI during admission from November 1999 to March 2000 were identified from the coronary care unit (CCU) records. Inpatient medication charts and outpatient records were then reviewed. Information collected included: ACE inhibitor use, doses, reasons for prescribing/not prescribing ACE inhibitors, and ACE inhibitor prescribers (cardiologists or general physicians). Results: Forty four patients with an MI were included in the study, 28 of whom were prescribed ACE-inhibitors (64%). Twenty four of the 28 patients on ACE inhibitors were prescribed perindopril. The major reason given for prescribing ACE inhibitors was signs of congestive cardiac failure. All ACE inhibitors initiated in patients after MI at RBH were ordered by cardiologists. Conclusion: ACE inhibitors were prescribed appropriately in 88% of patients who met criteria for their use. This high percentage of appropriate prescribing was encouraging. Reevaluation as part of an ongoing quality assurance activity could be used to ensure this is maintained.