Newsletter
2000
SICS annual scientific meeting 1999
The Society's eighth annual scientific meeting was organised by Roger
Hughes and Nigel Leary, and was held on Friday 30th January 1999 in
the Postgraduate and conference centre at Stirling Royal Infirmary.
The change of venue from the University was necessitated by an anomalous
booking and had advantages and disadvantages. The lecture theatre was
comfortable with good acoustics, and had good facilities including computer
projection. Altogether it was a friendly and comfortable venue but it
was unfortunate that there was not more space for lunch and for trade
exhibitors. These were crammed into the same area; however this may have
contributed to the fact that the many trade exhibitors to whom I spoke
felt that they had had a good meeting, with lots of interest from delegates!
Parking was problematical; some of those who drove down from the hotel
ended up walking further than those who opted to walk in the first place!
A satellite meeting on ARDS in the Stirling Royal Highland Hotel took
place on the Thursday afternoon preceding the meeting proper; and a report
of this appears later in the newsletter. The programme followed the tried
and generally approved format of some plenary lecture sessions and a
choice of workshops and case presentations. It was well balanced with
local and international speakers, and whilst including some news of cutting
edge research, it concentrated mainly on subjects that were of topical
and practical interest to clinicians working in the field.
The meeting was opened by Nigel Leary who presented details of the latest
programme change of which there had been several since the previous afternoon.
It was miraculous that he had any hair left by that stage! I hasten to
add that none of these changes occurred as a result of poor organisation
by the committee, but occurred as a result of various speakers' changing
work commitments and flight arrangements. Dr Howie then introduced Dr
Rachel Green, Director, West of Scotland Blood Transfusion Service who
wryly observed that she was the 'warm-up' act for Jean-Louis Vincent
speaking after her. She did however far more than just this, and outlined
the problems (or rather, lack of problems) with albumin, gave us a quick
run down on current thoughts relating to CJD and variant CJD in relation
to blood products, and produced a resume of the 1996-97 SHOT (Serious
Hazards of Transfusion) report. This latter included the incidence of
serious transfusion reactions and the incidence of HIV, HCV and HBV infection
found in donated blood. She concluded by outlining the problems facing
the BTS as we move into the new century, but ended on a reassuring note
by telling us that all British blood products would be leucodepleted
(at phenomenal cost) by the end of 1999.
Having thus warmed us up, Dr Green then introduced
Professor Jean-Louis Vincent from Brussels who was scheduled to speak
on, "Haemoglobin
Replacement - What Threshold, Which Solution", and he did just that.
He started by suggesting that we transfuse patients too readily and
suggested that we might reset our threshold for transfusion to a lower
value and relate it more to measurable changes in the patient's physiology
than to an absolute figure. He then addressed the thorny question of
blood transfusion and immunosuppression, outlining the evidence in terms
of increased transplant survival, tumour recurrence and infection, concluding
that most of the problems appear to be related to leukocytes in transfused
blood. It sounds as if the cost of leukodepletion of blood for transfusion
in the UK may prove to be money well spent. Before closing, Professor
Vincent gave us a quick history of the use of bovine blood haemolysate
and of polymerised pyridoxilated haemoglobin solutions and concluded
with a discussion of the relative values of nitric oxide scavenging solutions
Vs non-scavengers.
It has to be said that whilst Professor Vincent always speaks with great
erudition and with great clarity, it would not matter two hoots if he
did not, as his delightful accent, his extrovert style and expressive
gestures always make it a treat to be in his audience!
Dr Chris Garrard then treated us to a dissertation on ICU acquired pneumonia.
This was a very well balanced talk, touching on research showing the
protective effect of anti-IL10 in mice with pneumococcal pneumonia, a
quick review of current research in the cytokine field as it relates
to ventilator acquired pneumonia and a brief sortie into clinical infection
scores. This was followed by lots of useful practical information about
bronchial lavage and the microbiological interpretation thereof and an
evaluation of measures to reduce ventilator acquired pneumonia.
It should be noted that during the previous night's dinner Dr Garrard
had also demonstrated an authoritative knowledge of Chicago architecture,
a city in which he spent some years before returning to Oxford.
Professor Joachim Boldt seemed to have suffered all the travel related
ills that can befall a man endeavouring to get from Ludwigshaven to Stirling,
including late planes and a visit to Manchester en-route. Unfortunately
he did not arrive until after the meeting-proper was over, and the audience
had been much depleted - indeed Cameron Howie was winding up the meeting
when Professor Boldt appeared behind him! It was a great shame that this
speaker had so many problems reaching Stirling as when he did arrive,
he delivered a very well thought out and carefully rehearsed talk on
that thorny old question - 'Crystalloids, Colloids or Albumin' in relation
to hypovolaemia, coagulation, side effects and finally how to divine
the optimum volume of replacement.
The Workshops were as popular as always. There was standing room only
at that on Prone Ventilation, sponsored by Hill-Rom which was presented
by Jane Clayton, David Down and, Phil Haji-Michael, from Manchester.
This was a very popular choice with delegates from the nursing profession,
not only because there was a bit of knock-about comedy when we were shown
what could go wrong when attempting prone ventilation, but also because
the presentation combined a short review of the underlying principles
with a demonstration which clearly revealed a lot of practical expertise.
The Case Presentations were held in the main theatre as they invariably
attract a large audience, as they did on this occasion. Chaired by Graeme
Nimmo and Chris Garrard, these were well presented by Philip Korsar and
Sandy Binning. They were made all the more interesting by being interactive,
a facility made available to us by Baxter Healthcare, and were attended
by some fairly searching questions about management (a wonderful thing,
the retrospectoscope!). It takes courage to 'bare one's chest' (clinically
speaking) in public, and the presenters showed this quality admirably.
Evidence-Based Intensive Care is a topical and, rather difficult subject
that was explored by Professor Nigel Webster in another workshop. Despite
being asked at very short notice, Prof. Webster gave an open, balanced
overview of evidence based practice as it relates to several areas of
current interest such as ARDS treatment strategies, administration of
albumin and the role of pulmonary artery catheters. He also presented
an excellent critique of metaanalysis, outlining potential pitfalls.
Dr Richard Beale, in the workshop on immunonutrition, (sponsored by
Novartis) reviewed the published literature, and concluded that whilst
it was cost-effective practice in that it reduced infection and shortened
hospital stay it did not reduce overall hospital mortality.
After the meeting, the AGM of the Society was held, and was rather better
attended than it sometimes has been in the past. This was followed by
a most enjoyable dinner and then a valiant attempt by David Swann and
I, in the company of several other revellers, to drink the bar dry of
Laphroaig. I don't think we were successful, but a very good time was
had by all, and many formerly well guarded intensive care secrets were
revealed!
Overall the meeting was well received, but we will, for reasons of space,
return to our usual venue in Stirling University conference centre for
the meeting in 2000. After last year's difficulties over getting speakers
from abroad to the meeting in time, our next meeting will have greater
emphasis on home-grown talent!
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Poster exhibitions
The poster exhibition was smaller this year than usual, but was certainly
not lacking in quality. Among the more interesting posters to me
were:
"Assent for Patients in the Intensive Care Unit",
from a group at Aberdeen Royal Infirmary (and a visiting clinician
from New South
Wales.)
and
"Patients' Memories of the Intensive Care Unit",
by Stephen Marjoribanks, also of Aberdeen Royal Infirmary.
There was an elegent & erudite poster from
the Western Infirmary, Edinburgh entitled,
"Brain IL6 Production during SIRS is of
Extra-Neural Production"
and a group from Edinburgh Royal Infirmary presented a poster on
"Femoral Artery Bolus Thermodilution Cardiac
Output in the ITU"
The prize was won by the beautifully presented poster by Stephen Marjoribanks.
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ARDS satellite symposium
The Audit Group was initially contacted by Zeneca
Pharmaceuticals who were seeking collaboration with ICUs to provide
baseline data concerning
resource usage by ARDS patients. Following several meetings, the
Company confirmed its interest in using the 'impressive' Scottish
database
to achieve goals which would be beneficial to both the Company
and the Society. To this end Zeneca sponsored the Satellite Symposium
held on the evening preceding the Annual Scientific Meeting.
The aims of the symposium were to provide an up to date review of ARDS
in terms of epidemiology, pathophysiology and therapeutic strategies,
and to outline a projected, prospective, observational study of ARDS
utilising the SICS database. Three eminent clinicians, Professor C Hasiett,
Professor of Respiratory Medicine in Edinburgh, Professor N R Webster,
Professor of Anaesthesia and Intensive care in Aberdeen, and Dr IS Grant,
Director of Intensive Care at Edinburgh's Western General Hospital provided
us with the fruits of their research and their knowledge. The symposium
was well-attended and received with great interest.
Installation of modified Ward-Watcher software, which enabled both identification
of ARDS patients and prospective daily data collection on them began
in May. At the time of writing, the study is proceeding well. Although
identification of ARDS patients will cease in the New Year, data validation
and collation of additional data by Audit Group staff will continue well
into 2000, and it is hoped that the report will be issued that summer.
The success of this study is due to the diligent data entry by ICU staff
(both nursing and medical). Our appreciation is extended to Astra-Zeneca
for their continued support in what should be a very worthwhile project.
Fiona Mackirdy
Project Director
Scottish Intensive Care Audit Group.
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Reports from the regions
South east of Scotland Intensive Care Society
The first session of
1999 was at the Western General where Dr Bellingan discussed the proliferative
phase
of ARDS,
with other
contributions
from Neurosurgery and ICU on Meeting the Needs of Relatives. At
the Royal Hospital for Sick Children in April, Dr Dave Simpson kept us
up to date with the Scottish Paediatric Intensive Care Audit and
we had a lively discussion on the Use of Early Haemofilration in
Meningococcal
Septicemia. Moving on to St John's, Livingston, in May, we discussed
the Appropriate Management of Severe Burns of the Neck as well
as
Hebert's article on Transfusion Practice in the Critically ill
and a short report
on Iron Poisoning. In August, at Melrose, we discussed the Management
of Trauma and in October at the Queen Margaret Hospital, Dunfermline,
we were treated to some unusual case presentations - Sodium Valproate
poisoning and Unusual Infections Following Dog Bites. The year
concluded with a November meeting at the Royal Infirmary, Edinburgh when
we
achieved some consensus in our debate on How Best to Feed the Critically
Ill
and on the Merits of lmmunomodulatory Feeds. Meetings of the Group
are usually very well attended and discussion continues unabated
after the main meeting in a local hostelry.
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West of Scotland Intensive Care Society
The 98/99 session was particularly successful for the West of Scotland
Intensive Care Society. Once again there was an increased membership
with good attendance at all the meetings.
Excellent presentations were made by Dr John Griffiths on Nutritional
Support in ITU and Dr Andy Webb on the Optimal Resuscitation Fluid for
use in the Intensive Care Unit, but arguably the highlight of the calendar
was the Registrars' meeting at which there were three presentations of
extremely high calibre, ranging from a snapshot of intensive care medicine
in Malawi, the management of a patient with HOCM and sepsis and discussion
on inter-hospital transportation of patients.
The first meeting of this session was held on 18th November at which
Mr Giles Peek form Leicester introduced the concept of a national ECMO
centre for adult patients with ARDS, and discussed previous trials and
results and the forthcoming trial sponsored by the Home and Heath Department.
Forthcoming meetings have been provisionally scheduled for 22nd February
(Registrar presentation evening) and 6th April (discussion of medical
ethical issues in the ITU).
The meetings are preceded by a buffet supper, and non-members from all
non-anaesthetic disciplines are particularly welcome.
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Editorial-the end of the beginning
Alf Shearer decided that the Scottish intensive Care Society needed
a newsletter, and as so often when someone has a great idea, he was
encouraged
to get on with it. The result was Newsletter No. l published to great
critical acclaim in January 1996. Alf has worked very hard (I now
know how hard!) to produce a newsletter every year since. I marvel
at his
ability to gently persuade colleagues to write things for him, to
grasp so well what should be in the Newsletter and what would be
better left
out, and to pull it all together in time for the Annual Scientific
Meeting deadline each year.
I do not know if he decided that it was no longer
a sufficient challenge, or whether he had just plain "had enough",
but he handed over the responsibility to me last year. I shall try
hard to justify your
trust Alf!
Not having known Alf for very long, I did not feel up to writing an appreciation,
so lan Grant was very happy to do so.
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Dr Alf Shearer-a note from Ian Grant
The Scottish Intensive Care Society Newsletter is now in its 5th Annual
edition as a conduit of news to members of the society. We are tremendously
appreciative of Alf Shearer's work in establishing and developing
it. The newsletter is of course only a small part of Alf's contribution
to Intensive Care in Scotland over the 20 years since he was appointed
Consultant in Ninewells Hospital in May 1979.
He was a pioneer of computerised intensive care audit, establishing
a computer database on a Sirius computer (remember them? - 16bit, 128k
RAM, twin 51/4 floppy, 1.2 megabyte disc drive) in 1984, and later extended
his data-base to include the follow-up to one year after ICU discharge
through his locally designed 'CRAFT' system. One of many results of the
Dundee ICU audit was the prize-winning presentation at the 1997 Intensive
Care Society meeting which suggested that increased ICU workload was
associated with increased mortality.
With the advent of percutaneous tracheotomy, Alf used the Surgical Skills
Centre at Ninewells to establish a course on the technique, which is
popular with intensivists from all over the country. Another very practical
contribution benefiting us in the Western General ICU in Edinburgh has
been the 'SRIVID' slide rule which nurses use to control blood sugar
in patients receiving TPN. This a very labour-saving device for medical
staff - no more sliding scales to re-write, and it controls blood sugar
very well into the bargain.
It is also worth reminding readers that Alf Shearer's role in the birth
of this society was pivotal. He was the organiser of the first Scottish
intensive care meeting, sponsored by Lilly, which was held in January
1988 in Perth. This led to the formation of the Scottish Intensive Care
Society three years later. That first meeting - on infection in the ICU
- had celebrities such as the late Gillian Hanson and Iain Ledingham
as well as local speakers.
One has a shrewd suspicion that, having finished his stint as editor
of the Newsletter, he will re-appear in a new and equally important role
in Scottish Intensive Care. Many Thanks Alf.
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Percutaneous Tracheostomy Course
The Departments of Anaesthetics and Otolaryngology, and the Surgical
Skills Unit in Ninewells Hospital and Medical School Dundee, have
developed a one day course on Percutaneous Tracheotomy Under Endoscopic
Control.
There are 2 courses per year, usually in May and November. Since the
first one in 1996, there have been 9 courses with a total of 87 participants.
These have included 55 anaesthetists, 31 ENT surgeons and 1 general surgeon.
Twenty four were consultant career grade, and 55 trainees. Fifty three
came from outwith Dundee and of those 34 came from outwith Scotland.
It is predominantly a practical course with 1 trainer to 2 participants.
After an initial introduction and training/refreshing on the use of the
bronchoscope they are introduced to the percutaneous tracheotomy kits
on basic models. Alternating the role of operator and endoscopist with
a partner, each participant then has the opportunity to perform 4-6 tracheostomies
with each method on a realistic model.
The methods taught currently are the Giggs forceps method (Portex kit)
and the Ciaglia serial dilator method (Cook kit). The Ciaglia single
tapered dilator method may be introduced in the next course, depending
on clinical experience with the method in Dundee.
The courses to date have been sponsored by Kari Stortz, Sims Portex
ltd and Cook UK Ltd.
The next course is to be held on 24th May, 2000 and will accommodate
10 participants.
Applications are available from:
The Surgical Skills Unit,
Ninewells Medical School, Dundee.
Tel: 01382 645857
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President's report
Inevitably a time for reflection without giving an impression of self
satisfaction. In the two years of my presidency I believe we have
continued to progress as a society. Well established undertakings
such as postgraduate
courses driven by Dave Swann, and the newsletter, now in Bill Easy's
capable hands, have continued apace.
The audit has diversified with a separate research group established
and a funding base generated by collaborative research done in conjunction
with both Zeneca and Glaxo Welcome. A separate group has now been established
to make a study of ICU deaths utilising some aspects of the SASM methodology.
With the ARDS study now nearing completion Fiona will be undertaking
a quality of life follow up on the survivors. Simon MacKenzie continues
to nurture the diagnostic list conceived almost one year ago. He is now
working with ISD, with the intention that the audit facility will generate
an ICU SMR return. This will allow the contribution of intensive care
to national priority areas such as cancer to be fully recognised. In
the wake of the Audit Commission Report on intensive Care in England
and Wales, I was contacted by two newspapers. I described the success
of our adjusted outcomes, compared with those published by the Audit
Commission. Sadly a good news story is not a story in the NHS as far
as the media are concerned. In general I think Scottish Intensive Care
is a good news story.
Much thought and a little effort has been expended on developing a web
site for the society (scottishintensivecare.org.uk). We have been guided
in this by Steve Kettlewell, a fine chap in spite of his surgical background,
who has already set up a breast cancer site. Like stars in the night
sky this is an undertaking which appears to offer more and more opportunities
the more we look at it. To date we have a site established with funding
support in place from Bayer Pharmaceuticals. The newsletter and the annual
audit report will be displayed and we will advertise forthcoming, meetings,
moving towards offering registration on line. I am currently attempting
to 'commission' work for a number of individuals on aspects such as the
history of the society, guidance for trainees aspiring to a career in
intensive care and the origins and early development of intensive care
in Scotland, to which end I am seeking the names of medical staff who
were involved in this and who might be able to provide impressions of
that period.
If you have any suggestions regarding the site, or would like to contribute,
please contact fiona@scottishintensivecare.org.uk.
I believe the web-site will offer us improved communication with our
members in a far more interactive manner than has been the case to date
and possibly a mechanism for interacting with patients, where it could
offer both information and an opportunity for patients to communicate
their experiences. Finally we intend to have the site offer a gateway
to other relevant sites. Other ideas will be welcomed. Our intention
is for the site to be self-funding; however, once fully established,
it may offer revenue opportunities to further underpin our research activities.
At present we have not attempted to limit access to the site so that
all 'publications' will have to take this into account.
At the time of writing, the programme for the
Annual Scientific Meeting has been published thanks to Louie Plenderleith,
with some help from
friends. Quite by chance, this year we do not have the usual smattering
of international "stars". Over the years they have enhanced
our meetings, though not infrequently requiring last minute programme
adjustments to accommodate late travel changes or in some cases "no
show". Consequently the forthcoming meeting should run like clockwork?
I don't think I will ever forget attempting to bring the last meeting
to its conclusion as Professor Boldt appeared behind my back.
At long last we appear to be at the brink of an operational Bed Bureau
for Glasgow. The most recent stumbling block has been the creation of
the NHS Net which has precluded communication of Trust computers by modem.
Although it was anticipated that the Glasgow Trusts would be connected
to the NHS Net by the summer of this year, at the time of writing the
connection is incomplete. However concerns over intensive care services
around the New Year period have had the benefit of priortising this area
of work, and it is possible that a functional bed bureau, communicating
through a secure network, may be in place soon.
I now hand over to Peter Wallace. Though, unlike me, the presidency
of our society might not appear to be the pinnacle of his career to date,
I know how delighted he was to be invited to take it on. He brings unrivalled
experience at a time when a distinct identity for intensive care in Scotland
is so important in the context of devolution.
Finally thank you to all my colleagues in ICUs across the country who
invariably took on, with enthusiasm, the additional work, that underpins
the burgeoning activities of our society.
Cameron Howie
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Annual audit meeting 1999
The Scottish Intensive Care Society Audit Group (Ah... that wonderful
acronym!) has relied heavily on the talents, hard work and not inconsiderable
charm of Fiona MacKirdy not only for the collation and verification
of the data which makes our database of patients the biggest in Britain,
but also largely for the organisation of the annual audit meeting.
This load was initially shared by Mark Livingstone, later by Sandra
Donaldson, and now by Jane Ross, research sister, to whom I am indebted
for this summary of the last meeting.
The Society's 5th Annual Audit meeting was held on Friday 29th October
1999 at the education and Conference Centre Stirling Royal Infirmary.
The audit meeting was sponsored by Glaxo Welcome, which enabled the nursing
delegates to attend free of charge.
Cameron Howie opened the meeting with an introduction
to the first of two hot news items, the recently debated 'Consent in
Incapable Adults" Bill.
He explained that the Society had been in discussion with the Scottish
Office in relation to proposed legislation on the treatment of incapable
adults. Broadly speaking the legislation was welcomed, in particular
bringing clarity to the issue of consent provided by relatives for research
in intensive care. However, things are not finalised yet, and Cameron
will continue to represent our interests and those of our patients at
the (now) Scottish Executive.
Simon Mackenzie discussed linking data from the SICS diagnosis list
with the information and Statistical Division (ISD) at the Scottish Executive.
The adoption of new diagnostic classifications for Scotland had first
been suggested at the 1997 meeting with the aim of improving the inadequacies
of the current 'APACHE' classification in describing Scottish case mix
and hospital coding. Since then the diagnostic group have met and developed
a hierarchical diagnoses system, which has now been included in Ward
Watcher. Simon discussed this system and proposed two modifications that
will help alleviate some of the coding confusion. These are firstly,
to add the diagnoses that have been most frequently found to be missing,
and secondly, to add an 'Other' option for infrequent diagnoses. He reminded
us that use of this latter should be rare as it makes subsequent searching
of the database less satisfactory. These diagnostic modifications will
be available with the next software update. Simon then reviewed the establishment
of links with ISD, a requirement for the Audit's continuation of central
funding. He reiterated the importance of improving ISD data that describes
intensive care, perhaps with the addition of ACP fields from Ward Watcher
to the SMR 1 return, but intimated that automating the SMR 1 returns
is still some way off.
The third speaker of the morning, John Kinselia, introduced us to the
SICS Research Group, as yet in its infancy. He proposed that this would
be a resource and registry for multi-centre clinical trials within Scottish
ICUS. The group, which currently includes John Kinselia (Glasgow), Simon
Mackenzie (Edinburgh), David Noble (Aberdeen), Mark Worsley (Stirling),
lan Grant (Edinburgh), John Colvin (Dundee) and Fiona could provide advice
on study design and ethics approval application. Financial support for
agreed projects might be forthcoming from SICS funds that have been generated
from sponsored SICSAG studies. It was suggested that it would be of value
to have a clinical nursing member in the group; any ICU nurse who may
be interested should contact Dr Kinselia directly at the Glasgow Royal
Infirmary.
Simon Mackenzie then returned for his second performance of the day
and presented a proposal that a group within the Scottish Intensive Care
Society should conduct selective external case note reviews of mortalities.
The process would be not unlike the Scottish Audit of Surgical Mortality.
We were reminded that case note review was discussed in the early days
of the SICS audit and was also included in the current CRAG funding application.
The proposal was for a three-stage process.
1.Identification of patients for review.
2.ICU comments on a clinical
form relating to care given and adverse events.
3.The external review.
This proposal generated plenty of discussion from the floor with particular
reference to the potential workload. It was suggested that any unit should
be able to opt out if they felt that their workload was too great. It
was emphasised that this would be a valuable quality exercise in clinical
ICU practice.
After lunch Cameron Howie introduced 'League Tables Revisited', and
this stirred discussion in the light of the second hot news item of the
day, the Audit Commission's Report, 'Critical to Success'. In contrast
to comparable data published in this report relating to 50 English and
Welsh ICUS, our analysis of the SMR tables for ICUs in Scotland for the
years 1996 to 1998 demonstrated a strikingly narrow range. Cameron then
went on to discuss the follow up of our study into hospital deaths following
ICU discharge. Previous results had demonstrated that this peaked within
48 hours of ICU discharge. The data have now been examined in relation
to expectation of likely survival and expressed intention in relation
to readmission. This demonstrated a remarkable stratification with a
5% mortality in the group expected to survive who would have been readmitted
if necessary, compared with a 75% mortality in the group expected to
die who would not be readmitted. It was suggested that this categorisation
would facilitate meaningful audit of this population.
Dr Martin Hughes spoke next reviewing the current prospective, observational
study in ARDS patients in Scottish ICUS. He explained the methodology
used and presented preliminary, provisional analysis of the subject set
to date. The results discussed were generated on data collected on the
day of the diagnosis. As expected, isolated respiratory failure accounted
for 30% of patients with 70% having two or more organs failed. The mean
ICU stay was 12.2 days, with an ICU mortality of 54.5%. This critical
analysis would appear to show a mortality for Scotland which is higher
than that in recent publications from elsewhere. Martin went on to examine
these publications and discussed subject selection, methodology and analysis
of them. He concluded that the mortality would be similar if the same
criteria had been used.
Stephen Noble gave the first presentation of the 'renal' section. He
reminded the audience of the earlier Renal Respiratory Failure audit,
which looked at outcomes of patients receiving renal and respiratory
support in Scotland. His presentation then continued with the results
of a survey of the structure and process of renal replacement therapy
(RRT) in Scottish ICUS. The survey took place across 19 ICUs providing
RRT at that time and included audit data of RRT activity between July
1998 and June 1999. Research Sister Jane Ross administered a structured
questionnaire to one consultant per unit. The results showed an incidence
of RRT within the time period of 5.17%. Modalities varied widely as did
the RRT techniques used. There was an absence of formal protocols and
audit therapy. The predominant techniques were continuous or intermittent
haemofiltration (CVVH/IVVH) and the commonest anticoagulant, heparin,
which was perceived as cheap, convenient and effective.
Jane Ross then presented the nursing aspects of the renal survey. She
examined by questionnaire the education of ICU nurses in RRT, their role
in the therapy and finally specific aspects of renal patient care. In
3 units renal support was still provided solely by renal nursing staff
and this had a noticeable effect on job satisfaction, finances and staffing
levels within the renal department. Education and training was seen as
essential in the establishment of ICU based RRT and was predominantly
clinically developed. There was a definite void in the provision of professional
certified courses since the abolition of Professional Studies courses.
Patients care styles varied across the units and the increasing use of
support workers in the provision of the therapy was noted. Jane concluded
that ICU nurses had generally incorporated RRT into their role and showed
a keenness to continue the development.
The final renal session before coffee, was delivered
by Dr Paddy Gibson, Renal Consultant who entertained us with his talk
entitled "The
Old and New In Renal Anticoagulation" He explored the idea of an
ideal anticoagulation regime and discussed those available at the moment.
He then introduced several new pharmacological and non-pharmacoiogical
therapies, from citrate infusion to pre-filter saline dilution. Paddy
stressed that there were limited objective clinical studies to help clinicians
in their choice of anticoagulation therapy and concluded that the best
solution was to stick to what works for you and for your patients.
Brian Miller rounded off the afternoon with an open session entitled
'Searching and Reports using 'Wardwatcher'. Brian guided the audience
through various searching processes and provided a booklet for delegates
to take back to their units. More copies of this can be obtained from
Fiona or Jane on 0141 201 5271. He suggested that the next software update
would give much more expanded and sophisticated searching and reporting
facilities.
Fiona closed the meeting by thanking all speakers for their contributions
and GlaxoWelcome for their sponsorship.
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Training in Intensive Care Medicine
Training in Intensive Care Medicine has been run under the umbrella
of anaesthesia for 30 years. Whilst it requires restructuring, it
has not,
contrary to what some would have you believe, just been invented!
Training has recently been in turmoil, with conflict between the Intercollegiate
Board for Training in Intensive Care (ICB) and the Royal College of
Anaesthetics (RCA). Some may wish to represent this as an attempt by
the College to
turn back the clock, but I believe that most intensivists in Scotland
would see it as a return to reality. Over 90% of consultants working
in intensive care in Scotland are anaesthetists, and the vast majority
of trainees wishing to pursue a career in ICM choose to do so through
anaesthesia. The direction taken by the ICB was in danger of destabilising
current training arrangements. However a multidisciplinary approach
is generally to be welcomed, improvements need to be implemented, and
much
of the work of the ICB has been positive. Nevertheless an agenda which
discriminates for a very small minority of trainees does not, I believe,
carry the support of the majority of Scottish intensivists - the silent
majority. The activity of whose members, not all of whom practice intensive
care medicine, requires to be brought back into balance. Some Royal
Colleges may have an interest in controlling training that is disproportionate
with their clinical contribution. Intensive Care Medicine continues
to
develop towards an independent speciality. While intensive care remains,
de facto, a sub-specially of anaesthesia let us hope that progress
can be orderly. Meantime, trainees should consult with their Regional
Advisors
of both the ICB and the RCA.
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SICS Intensive Care Medicine courses 1999
After an initial flurry of courses, your Council have decided that
there are probably not sufficient potential delegates to hold courses
in each
centre every year. A course was therefore not held in Aberdeen in 1999.
However, two courses were held during the year, in Edinburgh in June,
and in Glasgow during November. Each course had 19 students ranging
from SHO to Consultants. As usual , anaesthetics was the primary
specially
for all the students. The format of the courses was unchanged using
a mix of lectures, workshops and symposia. In addition to what might
be
considered to be 'core topics' the Edinburgh course covered community
acquired pneumonia, pancreatitis and electrolyte problems in the ICU,
whereas the Glasgow course also encompassed the use and application
of evidence-based medicine, which stimulated much interest.
Since the Society has now run seven courses in more or less the same
format, it was decided to invite an educationalist to do a SWOT analysis
of the Glasgow course. Melanie van der Woning is based at Wolverhampton
University, has a critical care nursing background, and is heavily involved
in other areas of medical education such as ALS courses. Her report,
to David Swarm was generally very complimentary, but did identify some
points that would benefit from fine-tuning.
The success of these courses depends on all the contributors, but especially
on those who come and teach. In 1999 this was a total of 33, and their
hard work is gratefully acknowledged by the Society. Plans are already
in hand for two courses in 2000; the first in spring or early summer
in Edinburgh, and an autumn course in Dundee, organised by Sally Crofts.
Anyone wishing to participate as a student, or, especially as an instructor,
should contact Sally in Dundee or David Swann in Edinburgh.
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The Scottish Intensive Care Society
The Society was formed in 1991 and now is not only a forum for intensivists
(and let's not forget the anaesthetists with an interest in intensive
care), but also the organiser of a number of professional meetings
a year. It forms the focus for audit of the speciality in Scotland,
the
catalyst for the creation of an intensive care bed bureau, and will
become the lynch-pin of multi-centre intensive care research in the
country.
There are now 216 members, who are represented by colleagues who are
elected to the Council of the Society from all parts of the country.
The Council comprises: - the president who serves for 2 years; the immediate
past president who gives way after one year to a vice president for one
year; eight regional representatives who serve for two years and may
be re-elected for a second term in office, following which they may not
be re-elected for a further two years; and other non-voting members invited
by the council for specific purposes. The treasurer/secretary is elected
by the council from amongst its members and serves for three years. The
workload of this position is such that the posts will in future be separated.
The Council is currently comprised of:
President : Dr JC Howie, Glasgow, Victoria Infirmary (1998)
Also :Audit Organiser, SICS
Representative for Anaesthetics and Intensive Care on SSMAC
President Elect : Dr P Wallace, Glasgow, Western Infirmary (2000)
Also : Honorary Secretary, Assn. of Anaesthetists
Member of Committee on Training in Intensive Care Medicine, Royal College
of Anaesthetists
Member of Joint Committee on Good Practice, Assn. of Anaesthetists and
the Royal College of Anaesthetists
Treasurer/Secretary : Dr NP Leary, Melrose, Borders General Hospital
(1 997)
Regional Representatives:
North
Dr Ian Skipsey, Inverness, Raigmore Hospital (1998)
Dr David Noble, Aberdeen Royal Infirmary (1999)
Dr Sally Crofts, Ninewells Hospital Dundee (1999)
East
Dr David Swann, Edinburgh Royal Infirmary (1996)
Dr Alastair Mackenzie, Dunfermline, Queen Margaret Hospital (1997)
West
Dr Roger Hughes, Victoria Infirmary Glasgow (1996)
Dr William Easy, Vale of Leven Hospital (1997)
(Also newsletter Editor)
Dr Louie Plenderleith, Western Infirmary, Glasgow (1998)
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Forthcoming meetings
May I remind you of the forthcoming meetings:
The Annual Scientific Meeting, followed by the AGM and a good dinner
at the end of January each year.
The Annual Audit meeting, usually in October.
Also:
The ICS (UK) Spring Scientific Meeting in Harrowgate on 11th - 13th
May.
The ICS and Riverside Group Meeting, usually in London in December,
and for those of you with lots of money:
The Critical Care and Anaesthesiology Meeting in Montreal, Canada, starting
June 3rd.
Finally there are the regional meetings in the West and East of Scotland.
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