The aetiology of headache after lumbar puncture is related to the hole left in the dura after the needle has been withdrawn, which allows the cerebrospinal fluid to leak out of the subarachnoid space. The headache can persist for prolonged periods and predispose to subdural haematomas, which are associated with a high mortality. Tourtellotte showed that this headache could be significantly reduced by using smaller needles.1 Also, among needles of the same size, those with atraumatic blunt tips are associated with a lower incidence of headache. They produce a smaller hole in the dura by separating rather than cutting the elastic fibres, as occurs with the Quincke tipped needles. 2We carried out a questionnaire survey of departments of neurology and neurosurgery to see if these needles were used in the practice of diagnostic lumbar puncture and to assess how else departments may be trying to prevent headaches after lumbar puncture. Methods and resultsIn September 1996 we sent a questionnaire addressed to the "senior registrar" of all (n = 105) departments of neurology and neurosurgery in the United Kingdom, as listed by the Association of British Neurologists and the Society of British Neurological Surgeons. We asked specific questions about the practice in their department of diagnostic lumbar puncture. We sent a repeat questionnaire to non-respondents two months later.The table shows the results of the survey. Seventy one departments (68%) replied. Most departments performed lumbar puncture with the patients lying on their side. Equal proportions of neurology and neurosurgery departments used the 20 gauge spinal needles (the most commonly used needle in both groups). The Quincke tipped spinal needle was used by over 70% of departments in each specialty, and only about a third of departments in each specialty oriented the bevel of the needle tip to be parallel to the longitudinal axis of the spinal cord. Over 80% of the departments clinicians used bed rest as a prophylactic measure. Neurology departments were more likely than neurosurgery departments to use systemic steroids and epidural blood patch for the treatment of headache after lumbar puncture.
Summary We present the case of a 62‐year‐old man with severe cold agglutinin disease who underwent major colorectal surgery. Cold agglutinin disease is a condition in which auto‐antibodies, usually immunoglobulin M, cause red blood cell agglutination at decreased body temperature. Haemolysis may result. Agglutination results in impaired perfusion, resulting in symptomatic Raynaud's phenomenon and acrocyanosis. Haemolysis can result in anaemia and thrombotic events caused by microvascular occlusion, in addition to haemoglobinuria and renal failure. Peri‐operative hypothermia is common in all patients and may be associated with significant morbidity, but is potentially catastrophic in a patient suffering from cold agglutinin disease.
SummaryWe assessed the hourly occupancy of our intensive care unit by high dependency patients over an 8-week period using the criteria established by the Working Group on Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units published by the National Health Service Executive. High dependency patients accounted for 1914 bed hours (21.6%) out of a potential available total of 8880 hours. Measurement of Therapeutic Intervention Scoring System points and Acute Physiology and Chronic Health Evaluation II scores confirmed that categorising patients according to the new guidelines produced significantly different populations of patients. Mean (standard deviation) Therapeutic Intervention Scoring System points for intensive care status patients were 38.57 (10.40) compared to 21.66 (5.98) points for high dependency status patients (p`0.001). Median (range) Acute Physiology and Chronic Health Evaluation II score for intensive care status patients was 16 (1-45) compared to 11 (1-27) for high dependency status patients (p`0.0001). Calculating bed occupancy with different definitions for the whole of our intensive care unit population during the 8 weeks revealed a range of occupancies between 85.3% and 107.3%. We recommend that intensive care unit bed occupancy should be calculated in a standard manner nationally to allow comparison between units. We suggest that hourly occupancy be adopted as the universal method.Keywords Intensive care. ...................................................................................... Correspondence to: Dr P. Spiers Accepted: 2 October 1997 Following much adverse publicity about the transfer of patients needing intensive care between hospitals, the National Health Service (NHS) Executive has issued 'Guidelines on the Admission to and Discharge from Intensive Care and High Dependency Units' [1]. The authors felt that many patients remain on an intensive care unit (ICU) longer than necessary and that the development of high dependency units (HDUs) would mean that ICU resources would be used more appropriately. This sentiment has been echoed by other authors [2] who felt that the existence of an HDU would reduce the numbers of premature discharges from their ICU. We undertook this study in order to evaluate the amount of ICU resources that may be freed if an HDU were available, using the new guidelines [1] to categorise patients as either HDU or ICU status.Different ICUs use different definitions to calculate bed occupancy. A recent report of the British Transplantation Society Working Party on Organ Donation [3] collected information on bed occupancy from 173 units in the United Kingdom. Occupancy ranged from 25 to 137%, but the definition of bed occupancy was not stated and we suspect that each ICU had applied its own definitions, as we had done when completing the survey form. We are also aware that some ICUs include patients managed by the ICU team in other parts of the hospital in their occupancy figures. We therefore applied three different de...
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