SummaryAll admissions into a six-bedded intensive care unit were audited prospectively over a 2-month period. Data were collected daily and classified according to criteria for intensive care or highdependency admission. There were 30 planned admissions (72 bed days) following elective major surgery, seven admissions following semi-elective surgery (41 bed days) and 47 emergency admissions (185 bed days). Overall bed occupancy was 89%. Of 366 possible intensive care days, 66 (23%) were occupied by high-dependency patients. Of the planned admissions all but five were discharged within 2 days. There were 39 major complications during the study period requiring life-saving interventions and 16 lesser but significant complications. In 12% of patients discharge was delayed because of the absence of a high-dependency unit. Four patients were transferred to an intensive care unit in another hospital and four patients were discharged prematurely because other patients required urgent admission. Seven patients were refused admission and three patients scheduled for elective operations had their surgery deferred. We estimate that over the study period 22 additional patients could have been cared for if a high-dependency unit existed. The suggestion that high-dependency units will solve some of the shortages created by lack of intensive care beds [1][2][3] is unproven. It appears that high-dependency provision significantly reduces the rate of cancellation of major elective surgery [4] and one report suggests a 13% reduction in mortality in the year following its introduction [5]. A high-dependency unit also provides a useful intermediate facility where more complex therapy and monitoring can be provided safely and efficiently [6]. KeywordsWe audited all admissions to our general intensive care unit prospectively over a 2-month period to estimate demand for high-dependency care. MethodThe type of patient (intensive care or high dependency) was recorded daily according to the criteria for admission described by (Appendix). Every patient occupying an intensive care unit (ICU) bed was evaluated at 10 a.m. each day over a 2-month period and classified as requiring an ICU or high-dependency unit (HDU) bed. Although the unit has six beds it was possible to admit more patients than there were beds due to transfers or deaths in the preceding 24-h period. The data collected daily included the patient's name, age, sex, diagnosis, operation (where relevant), complications in the last 24 h, length of stay and ICU outcome. Hospital outcome was determined after completion of the study. We also collected details on the number of ICU transfers in and out of the unit, elective surgical cancellations, refusals for admission to ICU and requests for admission to HDU. FacilitiesThe hospital has a six-bed general ICU which forms the basis for this study. There is also a three-bed liver HDU, a six-bed thoracic HDU, a nine-bed cardiac adult ICU and a six-bed cardiac HDU; these units are not under our direct ResultsThere were 84 admissions in th...

Purpose: To assess the cerebral oximeter, which measures regional oxygen saturation (rSO~) con~nuously and noninvasively, as a cerebral monitor during carotid endarterectomy (CEA). The rSO~ was compared with Somatosensory Evoked Potentials (SSEPs) as an indicator for shunting and as a predictor of postoperative neurological deficits. Methods: Seventy-two consenting patients undergoing CEA with general anaesthesia were studied. Normocarbia, normothermia and normotension were maintained. Cerebral monitoring consisted of bilateral median nerve SSEPs and the INVOS 3100 cerebral oximeter with the sensor pad placed on the ipsilate~ forehead. Decreases in SSEP amplitude of 50% and in rSO~ of 1096 were considered clinically significant. Neurological assessment was performed at emergence from anaesthesia, 24 hr postoperatively and at discharge. The rSO~ changes were compared with SSEP changes and with neurological deficits, Statistical analysis was with chi square and analysis of variance. P < 0.05 was considered significant. ][~ulll~: During carotid artery damping, rSO 2 decreased from 72 --+ 8% to 68 + 9% and mean arterial blood pressure increased from 92 -+ 14. mmHg to 98 +_ 14 mmHg. In four patients, the carotid artery was shunted because of SSEP changes ~er cross-clamping. ~ve patients had ~ 10% decreases in rSO~ following clamp application. Changes in both SSEP and rSO~ occurred intwo patients. Three of the four shunted patients had transient postoperative neurological deficits. One patient had a transient deficit without changes in either monitor. There were no persistent postoperative deficits. Compared with SSEPs, rSO~ had a sensitivity of 50% and a specificity of 96%. Conclusion= Clinical experience with this evoMng technology is ongoing. Its role in neurovascuiar procedures has yet to be established.

Status epilepticus is a common neurological emergency, with overall mortality around 20%. Over half of cases are first time presentations of seizures. The pathological process by which spontaneous seizures are generated arises from an imbalance in excitatory and inhibitory neuronal networks, which if unchecked, can result in alterations in intracellular signalling pathways and electrolyte shifts, which bring about changes in the blood brain barrier, neuronal cell death and eventually cerebral atrophy. This narrative review focusses on the treatment of status epilepticus in adults. Anaesthetic agents interrupt neuronal activity by enhancing inhibitory or decreasing excitatory transmission, primarily via GABA and NMDA receptors. Intravenous anaesthetic agents are commonly used as second or third line drugs in the treatment of refractory status epilepticus, but the optimal timing and choice of anaesthetic drug has not yet been established by high quality evidence. Titration of antiepileptic and anaesthetic drugs in critically ill patients presents a particular challenge, due to alterations in drug absorbtion and metabolism as well as changes in drug distrubution, which arise from fluid shifts and altered protein binding. Furthermore, side effects associated with prolonged infusions of anaesthetic drugs can lead to multi-organ dysfunction and a need for critical care support. Electroencelography can identify patterns of burst suppression, which may be a target to guide weaning of intravenous therapy. Continuous elctroencephalography has the potential to directly impact clinical care, but despite its utility, major barriers exist which have limited its widespread use in clinical practice. A flow chart outlining the timing and dosage of anaesthetic agents used at our institution is provided.