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Context:Severe sepsis or septic shock.Aims:The aim of this study is to examine the effect of a fluid challenge on the B-type natriuretic peptide (BNP) and the hemodynamic state.Settings and Design:This observational study was conducted in an intensivist-led academic, mixed medical-surgical Intensive Care Unit.Subjects and Methods:Focused transthoracic echocardiogram, plasma BNP, and hemodynamic measurements were recorded at baseline and following a 500 ml fluid challenge in thirty patients. Independent predictors of the percentage (%) change in stroke volume (SV) were sought. Next, these independent predictors were assessed for a relationship with the percentage change in BNP.Statistical Analysis Used:Multiple linear regressions, Wilcoxon rank-sum test, t-test, and Pearson's correlation were used. Data analysis was carried out using SAS. The 5% significance level was used.Results:Using a multiple regression models, the percentage increase in SV was independently predicted by the percentage increase in mean arterial pressure, left ventricular end-diastolic volume/dimension (LVEDV/LVEDd), ejection fraction, and a decrease in Acute Physiology and Chronic Health Evaluation II score (P < 0.0001). Preload, measured using LVEDV1 (before the fluid challenge) was significantly larger in the fluid nonresponders (%SV increase <15%) vs. the responders (%SV increase ≥15%). Finally, the percentage change in BNP was positively correlated with left ventricular size at end diastole LVEDd, r = 0.4, P < 0.035).Conclusions:An increase in BNP soon after a fluid challenge may have some predictive utility of a large LVEDd, which in turn can be used to independently predict the SV response to a fluid challenge.

We performed a retrospective review of the technical evaluation database of the ICU, Chris Hani Baragwanath Academic Hospital, Johannesburg, SA. We obtained a convenience series of measurements This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.Background. Major issues around the implementation of point-of-care testing (POCT) include: user type, regulatory control, ongoing quality monitoring and limited guideline adherence. Objectives. To determine if there are significant differences in the results of a POC full blood count test between different levels of healthcare and non-medical 'lay' users compared with laboratory users (technologists/pathologists). Methods. This article retrospectively reviews the technical evaluation database of the intensive care unit (ICU), Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. We searched for samples analysed by doctors, clerks and laboratory personnel. A minimum number of 60 comparisons were required. Bland-Altman plots, Spearman's correlation and Passing-Bablok fit were used to analyse the dataset. Results. There were 72 comparisons for haematocrit (Hct), 98 for white cell count (WCC) and 137 for platelets (Plt) between the clerk and laboratory personnel. The correlations were 0.91, 0.96 and 0.92, respectively. All were statistically significant. Using the Bland-Altman method, there was good agreement between results of the clerk and those of the laboratory staff, with a mean bias of 0.5% (Hct), 0.1 × 10 9 /L (WCC) and 10 × 10 9 /L (Plt). An insufficient number of tests were performed by medical doctors for statistical comparison. Conclusions. With appropriate training, non-medical, non-healthcare lay users are able to perform a moderately complex POCT with similar accuracy as trained laboratory professionals. The focus should shift to equipment and quality management processes rather than the medical/technical qualification of the user.S Afr Med J 2019;109(12):952-956. https://doi.org/10.7196/SAMJ.2019.v109i12.13981 datasets from the ICU at Chris Hani Baragwanath Academic Hospital, Johannesburg, were generated or analysed during the current study.

Cuffed tracheal tubes are used to prevent loss of tidal volume during positive pressure ventilation, minimise pulmonary aspiration of gastric and oral secretions, facilitate respiratory monitoring and, in the paediatric population, reduce the need for repeated laryngoscopy due to incorrect tube size. [1][2][3] These goals are achieved by appropriate cuff inflation. Cuff pressure (CP) should be >25 cmH 2 O to prevent aspiration and <30 cmH 2 O to avoid damage to surrounding structures. [4,5] Obstruction to blood flow occurs when CP exceeds capillary perfusion pressure, resulting in ischaemia of the tracheal mucosa. Blood flow is impeded at CP ≥30 cmH 2 O in normotensive adult patients, with total obstruction of flow occurring at CP ≥50 cmH 2 O. [5] No paediatric studies have been performed to assess capillary perfusion pressure or the CP at which tracheal capillary blood flow is impeded. The extent of damage from increased CP is related to the absolute pressure exerted by the cuff and the duration of this pressure (mucosal damage is noted to occur within 15 minutes of exposure to high pressures), with a greater contribution being from the absolute pressure. [5,6] Injuries from high CP range from mucosal ulceration to tracheo-oesophageal fistula. [6,7] Low CPs are also associated with risks, including the development of ventilator-associated pneumonia secondary to aspiration and compromised ventilation resulting from loss of positive pressure. [1,8] Internationally accepted consensus guidelines for optimal CP range and frequency of measurement are lacking. [9] A local nursing guideline suggests a CP range of 25 -30 cmH 2 O. [10] The 2015 American Heart Association Pediatric Advanced Life Support guidelines recommend using the manufacturer's specification for appropriate CP in children <9 years and suggest a reference range of 20 -25 cmH 2 O. [11] CP should be measured using a manometer or pressure transducer, as techniques such as digital palpation and the minimal leak technique Background. Intubated patients with a high tracheal tube cuff pressure (CP) are at risk of developing tracheal or subglottic stenosis. Recently an increasing number of patients have presented to our hospital with these complications. Objectives. To determine the frequency of tracheal tube CP measurements and the range of CP and to explore nursing knowledge regarding CP monitoring. Methods. Frequency of CP measurement was assessed using a prospective chart review, followed by an interventional component. In the final stage nurses completed a self-administered questionnaire. Results. A total of 304 charts from 61 patients were reviewed. Patients' ages ranged from 1 to 71 years, with a male preponderance (1.5:1). The majority of charts (87%) did not reflect a documented CP measurement and only 12 charts showed at least one measurement per shift. Only 17% of recorded CPs were within the recommended range; 59% were too low. The questionnaire was completed by only 51% of the 75 respondents. Nursing experience ranged from 3 to 35 years and 92% of ...

This prospective observational study evaluates the relationship between adrenaline, lactate and intensive care unit survival in septic shock. Forty patients requiring adrenaline therapy for a first episode of septic shock acquired >24 hours after admission to the intensive care unit had blood lactate levels measured two-hourly over a 24-hour period. Adrenaline therapy was escalated until target mean arterial pressure was reached. The lactate index was calculated as the ratio of maximum lactate increase to the adrenaline increase. Lactate increased from 2.3 to 2.9 mmol.l-1 (P=0.024) and the mean adrenaline increase was 0.14 μg.kg-1 .minute-1. Peak lactate correlated with peak adrenaline (rho=0.34, P=0.032). Lactate index was the only independent predictor of survival after controlling for age and Acute Physiological and Chronic Health Evaluation II score (odds ratio 1.14, 95% confidence interval 1.03 to 1.26, P=0.009). A high lactate following adrenaline administration may be a beneficial and appropriate response.

Intravenous fluid administration is a vital compo nent in the resuscitation of critically ill patients [1]. Previously the clinical practice guiding the choice of fluid used in resuscitation has been predominantly governed by the opinion of the treating physician [2]. However, over the past decade there have been a va riety of publications on this matter that can assist in guiding the treating physician [3][4][5][6]. In 2012, two landmark studies were published against the use of hydroxyethyl starches (HES) [3,4]. The 6s study group found that when comparing resuscitation using HES versus resuscitation using acetated Rin gers in patients with severe sepsis, those who were resuscitated with HES had an increased risk of death and were more likely to require renal replacement therapy [3]. Similarly, the CHEST study group found that when comparing HES use versus saline in inten sive care patients, those resuscitated with HES were more likely to require renal replacement therapy [4].

Background Globally, one of the major problems facing health systems is an acute deficit of health workforce. To ensure equitable distribution and deployment of health workers, up-to-date and timely information on the health workforce is vital. Health workforce registries (HWRs) have the potential to generate data for evidence-based human resource planning and policies. There is a lack of evaluative research on the capacity of HWRs to improve health systems. This review aims to assess the effectiveness of HWRs for improving health systems in low- and middle-income countries. Methods We searched selected electronic databases from inception to 14 April 2020. Two authors independently screened studies and extracted data from included studies. We presented results as a narrative synthesis. Results We included eight studies of moderate–high quality in this review. The results suggest that HWRs can improve the distribution and skill-mix of the health workforce, quality of health workforce data, availability and use of data for policy and planning, and user satisfaction. The evidence was derived from case studies, which limited our ability to infer a causal relationship. Conclusion More rigorous research from controlled experimental studies is needed to consolidate the available evidence from observational studies.

Background: Age, body mass index (BMI) and pre-existing comorbidities are known risk factors of severe coronavirus disease 2019 (COVID-19). In this study we explore the relationship between vitamin D status and COVID-19 severity.Methods: We conducted a prospective, cross-sectional descriptive study. We enrolled 100 COVID-19 positive patients admitted to a tertiary level hospital in Johannesburg, South Africa. Fifty had symptomatic disease (COVID-19 pneumonia) and 50 who were asymptomatic (incidental diagnosis). Following written informed consent, patients were interviewed regarding age, gender and sunlight exposure during the past week, disease severity, BMI, calcium, albumin, magnesium and alkaline phosphatase levels. Finally, blood was collected for vitamin D measurement.Results: We found an 82% prevalence rate of vitamin D deficiency or insufficiency among COVID-19 patients. Vitamin D levels were lower in the symptomatic group (18.1 ng/mL ± 8.1 ng/mL) than the asymptomatic group (25.9 ng/mL ± 7.1 ng/mL) with a p-value of 0.000. The relative risk of symptomatic COVID-19 was 2.5-fold higher among vitamin D deficient patients than vitamin D non-deficient patients (confidence interval [CI]: 1.14–3.26). Additional predictors of symptomatic disease were older age, hypocalcaemia and hypoalbuminaemia. Using multiple regression, the only independent predictors of COVID-19 severity were age and vitamin D levels. The patients exposed to less sunlight had a 2.39-fold increased risk for symptomatic disease compared to those with more sunlight exposure (CI: 1.32–4.33).Conclusion: We found a high prevalence of vitamin D deficiency and insufficiency among patients admitted to hospital with COVID-19 and an increased risk for symptomatic disease in vitamin D deficient patients.