Newsletter
1999
SICS annual scientific meeting 1998
The society's seventh annual scientific meeting was organised by Dr
Roger Hughes with the help Dr Nigel Leary and it was held on Friday,
30th January, 1998 in the University of Stirling. Considering the quality
of the speakers and the programme, the attendance was disappointing compared
to the previous year. One hundred and one delegates, however, including
29 nursing staff, enjoyed a first class meeting.
Dr lan Grant, the society's president, opened
the meeting by introducing Professor Luciano Gattinoni from Milan who
delivered a fascinating talk
on the subject of "ECMO". He traced the changing perception
of pulmonary pathophysiology in ARDS over the last 20 years and the subsequent
approaches to supportive therapy. Ventilatory support strategy has gradually
evolved to reduce lung damage but balancing the iatrogenic cost against
benefit is a major problem especially when comparing treatments. He described
the changes in entry criteria for ECMO over the years and the difference
between centres. In Milan, ECMO is used when all else fails and they
are treating sicker patients than previously. They are treating fewer
patients but for much longer periods. Although the overall mortality
associated with treatment is greater, they are not treating many who
would survive without ECMO. He described the practical details and the
clinical management of patients on ECMO and during the weaning process.
There were workshop sessions after coffee as
at the previous year's meeting. This time there was a choice from five.
These ran concurrently
and were repeated for a second run, giving delegates the opportunity
to attend any two of the five workshops. Dr Peter Wallace gave an update
on the "New Exam And Training" in intensive care medicine.
He did his best to answer the many questions with regard to the exam
and what would be accredited for training. The system,was in an early
state of evolution, however, and many answers depended on decisions to
be made by the intercollegiate board and its subcommittees. The "Case
Reports" was a popular and successful workshop in which the presenters
had the privilege of questions from a critical audience, including Professor
Gattinoni. The cases presented were:- "Phaeochromocytoma presenting
in pregnancy" by Dr Mary Rose and Dr Carol Macmillan from Dundee; "A
pressing case" by Dr Andrew Longmate from the Western General Hospital,
Edinburgh; "Varicelia-zoster pneumonitis" by Dr John Hunter
from Aberdeen; and "A case of ARDS and HAT" (Heparin Associated
Thrombocytopenia) by Dr Charlotte Gilhooly from Glasgow Royal Infirmary.
Professor Bob Bartiett from Ann Arbor, Michigan, made his vast experience
available in a workshop on "Research In Intensive Care". As
well as giving an American perspective of research, such as that aimed
at the pulmonary artery catheter controversy, he also tackled some of
the ethical dilemmas, including those arising in the study of the use
of ECMO in children. Sister Helen Dickie gave an "Update On TISS
Working Group" with a detailed account of SOPRA (System Of Patient
Related Activities) including its derivation, content and validation.
It is a much more comprehensive, meaningful and useful scoring system
than TISS and the pilot version was about to be launched. "Ethics
And Decision Making In Intensive Care" was an interesting workshop
run by Ms Frances McGeoch from the Abbey Carrick Glen Hospital, Ayr.
With the help of volunteers and audience participation, she demonstrated
the use of Socratic dialogue to address difficult issues.
After lunch, Dr Nigel Leary introduced Dr Peter
McQuillan from Portsmouth who gave an excellent talk on "Redesign Of Acute Medical Care".
He presented the findings of a pilot study which were rather worrying,
seeming to show that the quality of care of severely ill patients prior
to intensive care admission is frequently substandard and this has a
major impact on outcome for patients, as well as the requirement for
intensive care.
Recognition that the problem exists is a major hurdle. To improve the
situation, he suggested, many aspects of the process would have to be
looked at. Attitudes and roles may have to change. Training and maintaining
standards are vital, as is the strategy for recognition and care of sick
patients. Major re-organisation may be required and he outlined possible
models.
Professor Bob Bartiett was introduced by Dr Cameron
Howie and his talk entitled "Partial Liquid Ventilation And Other Developments" was
interesting and certainly educational, as well as fascinating and entertaining.
He spoke first about the multitude of treatments that have been tried
in ARDS. Many of us had never heard of some of these, supersaturated
oxygen solution and atrial septostomy for example. The latter is advocated
for preventing death from right ventricular failure. Although ECMO is
standard therapy in neonates in Ann Arbor and it is used in adults, a
prospective randomised trial is in the pipeline to determine whether
its use is justified in adults. It was his account of partial liquid
ventilation which most of the audience found amazing. Perflubron which
is a perfluorocarbon is poured into the lungs to fill the FRC, and IPPV
is applied using
a standard ventilator. It not only improves gas exchange, but it seems
to be safe and it seems to have a beneficial effect on the acute lung
injury, although an ongoing trial has not yet confirmed this.
The poster competition was judged by Professor
Bob Bartiett and Mr Cari Davis (Paediatric Surgeon, Yorkhill Hospital)
and the prize was awarded
to Dr Kariet Yassen from the Royal Infirmary of Edinburgh for "Serum
phosphate concentration during and after orthotopic liver transplantation".
A.J. Shearer
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Irish and Scottish Intensive Care Societies joint scientific meeting
After several years of scheming Dr Ken Lowry and Dr David Swann finally
brought the Celtic intensive care societies together for a joint meeting
which must surely be repeated in the future. Although the Scottish contingent
was relatively small, the total attendance was about 100 and the Spires
Conference Centre in Belfast provided a very apt venue for the meeting
on the llth and 12th June, 1998.
The meeting began on the Thursday afternoon with
a session on the Lung. Dr Barry Kelly from The Royal Victoria Hospital
in Belfast provided an
education on "The Radiology Of Acute Lung Injury"; Professor
Nigel Webster from Aberdeen presented the state of play and detailed
practical advice on the administration of "Inhaled Nitric Oxide
In The Adult ITU"; and Dr Brian Keogh from the Brompton Hospital
in London presented a comprehensive review of "Ventilatory And Positional
Strategies" in the management of ARDS. The "Clinical Cases" which
followed stimulated lively and entertaining
audience participation and demonstrated the educational
value of this type of session when well conducted. Dr K. Crowley from
Dublin presented
a case of fatal complications following a dental abscess; Dr T. Ryan,
also from Dublin, demonstrated the diagnostic problems created by systemic
candidiasis after a perforated duodenal ulcer; and the session ended
with a case of multiple organ failure caused by "Scarlet Fever:
A Ghost From The Past" presented by Dr Carol Murdoch from Glasgow.
The afternoon ended with the keynote address on "Occult Hypovolaemia
And Perioperative Optimisation In High Risk Patients" by Professor
Graham Ramsay, a Scottish surgeon who is director of intensive care in
Maastricht. This was a succinct and interesting talk which demonstrated
how earlier detection of hypoperfusion than is usually the case with
current practice and earlier use of simple fluid therapy can make all
the difference to the outcome.
After an enjoyable evening with dinner in the
latest version of the Europa Hotel and drinks before and after in real
Irish pubs such as the
Crown and Robinsons, it is not surprising that not all of the delegates
turned up for the breakfast workshop on the Friday morning. However,
the abstemious Dr Nigel Leary had bravely agreed to discuss "Perioperative
Treatment Of The High Risk Surgical Patient: A District General Hospital
Experience" and was rewarded with an appreciative, though small,
audience.
The main meeting started with a free paper session which included 2
Scottish and 4 Irish papers. Dr K. Brown from the Royal Infirmary of
Edinburgh presented a series of ICU patients post emergency transjugular
intrahepatic portosystemic
shunt (TIPSS) for variceal bleeding. Measures
of liver function at presentation did not predict death but all patients
who developed renal failure died.
Dr Helen Galley from Aberdeen presented data which suggested that in
severe sepsis the Th2 T-heiper-cell-mediated immune response predominates.
This, mainly humoral response, is likely to lead to fibroblast activation
and immunosuppression, and modulation of the balance of the T helper
cell differentiation should be explored as a therapeutic option. Dr C.
Murphy from Dublin's Mater Misericordiae Hospital had identified a 20%
incidence of bacteraemia at the time of elective changes of central venous
catheters in patients receiving parenteral nutrition. This bacteraemia
was thought to be associated with manipulation of a previously colonised
line and more than doubled the risk of sepsis in the subsequent line.
Dr Philip Lockie from Queens University Belfast demonstrated that trauma
patients have reduced concentration of naturally occurring antibodies
to endotoxin. This is probably due to specific consumption and provides
indirect evidence of endotoxaemia following major trauma. Dr B. Golden
from St Vincent's Hospital Dublin produced the results for patients admitted
to their ICU with meningococcal septicaemia. Treatment with protein C
was not used in their unit and the results were no different to those
published by another group who did use protein C therapy. Dr C. O'Malley,
also from St Vincent's Hospital, demonstrated that triglyceride can be
assayed as a marker of the feed content in gastric aspirate and that
using the volume of the aspirate alone as an indicator frequently underestimates
the success of nasogastric feeding. The prize of £250 for the best
free paper was awarded to Dr Philip Lockie.
The second half of the morning was devoted to "The Kidney" with
the now famous double act of Dr Liam Plant from the Royal Infirmary of
Edinburgh and Dr Keith Simpson from Glasgow Royal Infirmary. With entertainment
and phenomenal clarity they explored the pathophysiology of "Selected
Paradigms Of Renal Disease In The ICU" and focused on an evidence-based
approach to their management. They covered the epidemiology of acute
renal failure and concentrated on the particular areas of ischaemic/toxic
acute renal failure/ tubular necrosis, hyperkalaemia, and the place of
renal biopsy.
The subject for the afternoon was "Subarachnoid Haemorrhage".
Mr Mike O'Sullivan, consultant neurosurgeon, from the Western General
Hospital Edinburgh set the scene with an informative talk on "Subarachnoid
Haemorrhage: Past, Present and Future", covering non-
surgical as well as surgical aspects of management,
including coil technology for the treatment of aneurysms and the use
of "triple H" therapy
(i.e. hypervolaemia, haemodilution and hypertension) for
vasospasm. Dr Graham Nimmo and Dr lan Grant, both also from the Western
General, and Dr Rory Dwyer from Dublin brought us up to date with the
intensive care management of subarachnoid haemorrhage with particular
emphasis on the treatment of vasospasm and neurogenic pulmonary oedema.
There were 1 0 posters exhibited at the meeting:- 5 from Dublin, 2 from
Belfast, and 1 each from Aberdeen, Glasgow and Carlisle. The prize for
the best was split between:-
Closed tracheal suction in ICU: Its effects on delivered tidal volume
and forced expiratory lung volume. McCarroll C, Lavery G, Coogan T. Royal
Hospitals Trust, Belfast; and - An audit of the outcome for combined
renal and respiratory failure in Scottish ICUS. Noble JSC, MacKirdy FN,
Donaidson SI, Howie JC. Victoria Infirmary, Glasgow.
A.J. Shearer
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Poster exhibits
The following is a list of the posters exhibited at the SICS Annual
Scientific Meeting at Stirling University on Friday, 30th January 1998:-
The neuroendocrine and immunomodulatory effects of dopamine. Hunter
JD, Noble D, Heyes SD, Eremin 0. Department of Anaesthetics and Intensive
Care, and Department of Surgery, Aberdeen Royal Infirmary, Aberdeen.
TIBET.. therapeutic interventions before transfer. Tan TK, Anderson
L, McKinnon S, Binning A. Clinical Shock Study Group, Western Infirmary,
Glasgow.
Temperature changes in patients undergoing secondary transport: a pilot
study. Tan TK, Binning A. Clinical Shock Study Group, Western Infirmary,
Glasgow.
Evaluation of predicted and actual length of stay in 22 Scottish ICUs
using the APACHE Ill system. Woods AW, MacKirdy FN, Livingston M, Howie
JC. Department of Anaesthetics, Victoria Infirmary, Glasgow.
Survey of medical admissions to ICU using a pre-admission scoring system
for detecting the development of a critical illness. Egeler C, Howie
JC. Department of Anaesthesia, Victoria Infirmary, Glasgow.
Pulmonary lactate production in patients with fulminant hepatic failure.
Walsh TS, Hopton P, Mackenzie SJ, Lee A. Department of Anaesthetics,
Intensive Care Unit and Scottish Liver Transplant Unit, Royal Infirmary,
Edinburgh.
Serum phosphate concentration during and after orthotopic liver transplantation.
Yassen K, Lee A. Department of Anaesthetics, Intensive Care Unit and
Scottish Liver Transplant Unit, Royal Infirmary, Edinburgh.
ECG abnormalities: an investigation into ECG changes in ITU patients
with acute brain injury from trauma and subarachnoid haemorrhage. Macmillan
CSA, Andrews PJD, Struthers AD. Departments of Anaesthetics and Clinical
Neurosciences, Western General Hospital, Edinburgh; and Clinical Pharmacology,
Ninewells Hospital, Dundee.
Agreement and artifact: comparison of a miniature strain gauge transducer
with an invasive pressure monitor and a water column, and its reliability
in a MR scanner. Macmillan CSA, Wild JM, Marshall 1, Armitage PA, Cannon
J, Easton VJ,
Wardlaw JM, Andrews PJ. Departments of Clinical Neurosciences and Medical
Physics, University of Edinburgh.
MR imaging in traumatic brain injury: complimentary proton MRS and diffusion
weighted imaging in intensive care patients. Macmillan CSA, Wild JM,
Armitage PA, Wardlaw JM, Marshall 1, Bastin ME, Cannon J, Andrews PJ.
Departments of Clinical Neurosciences and Medical Physics, University
of Edinburgh.
Acute brain injury: poor outcome associated with elevated jugular bulb
saturation. Macmillan CSA, Andrews PJD, Jones PA, McKeating EG, Easton
VJ, Hovells T Department of Anaesthetics and Clinical Neurosciences,
Western General Hospital, Edinburgh.
Displayed but not part of poster competition:-
Audit of combined renal and respiratory failure in Scottish ICUS. Scottish
Intensive Care Society Audit Group.
The relationship between the presence of pulmonary artery catheters
during the first 24 hours of intensive care and outcome: update. Scottish
Intensive Care Society Audit Group.
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Transport of the critically ill in Scotland
Following the meeting held in the Western Infirmary in June 1997, reported
in last year's newsletter, the Society in conjunction with the Scottish
Ambulance Service began the development of a series of courses on the
Transport of the Critically Ill. As these courses were aimed at a wide
range of staff involved in this area, it was decided to develop them
in a form analogous to the ATLS, with a series of relatively fixed lectures
which could be delivered in various parts of the country.
The course development team came from a range of backgrounds (ambulance,
anaesthetics, accident and emergency, paediatrics, and nursing) but all
had active experience in this area:-
Mr Andrew Marsden Scottish Ambulance Service
Dr Philip Booth Paediatrics,
Aberdeen
Dr Louie Plenderieith Anaesthetics, Glasgow
Dr Philip Korsah Shock Team,
Glasgow
Dr Susan Midgely Anaesthetics, Edinburgh
Mr John Hiscox A & E, Aberdeen
Dr Anne Blyth Anaesthetics, London
Mr Graham Percival Nursing, Edinburgh
Dr George Smith Anaesthetics, Aberdeen
Ms Laura Johnstone Nursing,
Aberdeen
After much discussion, the agreed format was:-
An introduction from the Ambulance Service on the facilities available
for transport, including land ambulances, fixed wing aircraft and helicopters,
with their benefits and problems; lectures on physiology and equipment;
a demonstration of various transport trolleys and the equipment carried
in a front line ambulance; lectures on the problems of transferring the
critically ill patient, the critically injured patient (including burns
and neurotrauma) and the critically ill neonate and child; and case presentations
illustrating the problems which could be encountered.
The first set of lectures has been given throughout the year at the
Scottish Ambulance Headquarters in Peebles, Aberdeen Royal Infirmary
and the Kelvin Conference Centre in Glasgow. There was almost a maximum
attendance at each and they were well received. Participants came from
a wide range of backgrounds including ambulance personnel, nurses, trainee
and consultant medical staff, as well as general practitioners in isolated
areas. Feedback was obtained from all the courses and this has enabled
us to continually improve the course over the year.
It is intended to continue this course next year as well as developing
new courses. The Civil Aviation Authority requires both a pilot and another
person with sufficient training in aircraft safety on a passenger carrying
flight. It is therefore planned to develop a course which covers both
aircraft safety and the patient aspects of air transfer in more detail
than the above course.
J.L. Plenderleith
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Intensive Care Medicine course
The only one of the three planned courses to take place in 1998 was
held in Aberdeen on 28th and 29th September. That course, which was the
first of these in Aberdeen, was held in the
Postgraduate Centre at Foresterhill and was directed by myself. My direction
was distinguished mainly by an incredible and probably unbearable neurosis
prior to the course starting. However, this concern was quite needless
thanks to the support and advice of David Swann and the high standard
of instruction and enthusiasm of all the instructors.
There were 17 participants and, as has been a feature of previous courses,
they ranged from SHO to consultant. The programme followed the now familiar
pattern of a mixture of lectures, workshops and symposia. A wide range
of topics were covered such as nutrition, cardiovascular support, ethical
issues, poisoning, burns and smoke inhalation.
Feedback from the participants was excellent. It was presented both
informally, at a local bistro taken over for the night by most of the
candidates and instructors, and formally by written evaluation at the
end of the course. We look forward to hosting another course in Aberdeen
sometime in the future.
R. Patey
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Annual audit meeting
The Society's 4th Annual Audit Meeting was held
on Friday 30th October 1998 at the Education & Conference Centre,
Stirling Royal Infirmary. Despite a clash with 2 other relevant meetings,
attendance was the best
yet.
At the 1997 SICS Audit Meeting, it was suggested that a new diagnostic
classification could be adopted across Scotland to improve the inadequacies
of the current 'APACHE' classification to describe case-mix in relation
to hospital coding. To this end, a group, including Gillian Adey, Cameron
Howie, John Kinselia, Simon Mackenzie, Fiona MacKirdy and Louie Plenderieith,
has been considering ways of improving the situation. Simon Mackenzie
gave the first presentation of the day, outlining the proposal the group
has reached. The proposal is that we record, in addition to the APACHE
diagnostic categories: 1) the reason for ICU admission, as one of a)
the primary diagnosis, b) nature of surgical procedure itself, c) unexpected
complication of surgery/treatment, or d) multiple organ support; and
2) multiple diagnoses from a standard list. Such a list would be accessed
in a hierarchical would be accessed in a hierarchical manner on Ward
Watcher.
Louie Plenderleith described a significant problem within all available
scoring systems, which derives from poor uniformity of fit of the model
across major diagnostic and admission categories. This is exemplified
in APACHE 11 where postoperative patients have a significantly lower
SMR than those admitted from the ward. He elegantly demonstrated that
the apparently substantial variation in SMRs between individual ICUs
in Scotland could arise purely as a function of their case mix. Although
he did this for APACHE Ill we are aware this problem exists in all of
the scoring systems. To date we have dealt with this problem by showing
separate SMR tables for operative and non-operative patients. We are
aware that the best way to deal with this problem is to customise the
available models to remove, or significantly reduce, the variations in
performance across the major categories of diagnosis and source. This
was dealt with in the subsequent presentation by Fiona MacKirdy.
Fiona first of all demonstrated the importance of having an adequate
patient volume available when assessing relative performance by individual
ICUs using the SMR. An important message from this
PowerPoint presentation was the extent to which relative performance
varies yearon-year. Very few ICUs demonstrated consistent rank order
performance across the 3-year period. In one case this was explicable
by unusual case mix. Thus the Western General Hospital (Edinburgh), which
takes a large number of patients with a neurological diagnosis, had a
consistently poor rank order performance. Fiona was able to demonstrate
that this was due to the high SMR associated with neurological conditions.
Work by Simon Mackenzie, utilising the GCS score available prior to ICU
admission where scoring is precluded by concurrent sedation, has previously
demonstrated correction of this deficiency. Fiona went on to demonstrate
SMRs from a customised scoring method based on APACHE 11 physiology and
APACHE Ill diagnoses, which Mark Livingston has developed. This method
shows much better uniformity of fit. Consequently, there is less variation
in ICU performance and the Western General in particular, zips from one
end of the league table into the top 25%.
Assessment of ICU length of stay against an expected ICU length of stay
could be used as a measure of quality of care. A prediction of ICU length
of stay had been developed by APACHE Medical Systems 1 nc. as part of
the APACH E 1 1 1 severity of illness scoring system. Dr Andrew Woods,
SpR in Anaesthetics, presented analysis of this predictive tool. His
evaluation demonstrated a satisfactory correlation when patients are
grouped by predicted duration of stay. However, there is an overall overestimation
of length of ICU stay in the Scottish ICUS. This APACHE Ill-based model
is not in the public domain. Consequently, rather than trying to customise
this model, we intend to attempt to develop our own model based on similar
information. To this end, further work is ongoing with Mr John Norrie,
Senior Statistician at the Roberlson Centre for Biostatistics at the
University of Glasgow.
At the 1997 Annual Meeting, Colin Selby presented data on ICU admissions
with acute asthma set against the background of total asthma admissions
to Scottish hospitals during the same time period. This demonstrated
a mortality rate, somewhat higher than would have been predicted by the
severity of illness scores. Following demonstration of a higher mortality
than predicted in our asthma patients, a casenote review was instituted
by Dr Martin Hughes, SpR in Anaesthetics. His presentation was based
on an initial review of the 'asthma' deaths previously reported. He demonstrated
that the problem lay in placing COAD-type patients in the asthma diagnostic
category. Of the 13 deaths, only 3 were acute asthma, 2 of which suffered
out of hospital cardiac arrests. Martin proposes to undertake case-note
review of all patients classified as asthma to determine the true mortality
rate for this condition. As part of this presentation he presented a
literature review which demonstrated a clear improvement in outcome for
this condition in recent years. He conjectured this might be related
to differences in ventilator strategies which minimise barotrauma.
The next presentation by Keith Simpson was once
again a follow-up to a presentation given by Stephen Noble at last
year's meeting. While Keith
opened his presentation by emphasising the limited role which he has
taken in this study his subsequent presentation left no one in any doubt
as to why he had been invited to speak. Three clear messages were apparent
from this presentation. First of all data entry errors, in this case
involving TISS, have the capacity to deliver quite spurious information
on outcome. Secondly, outcome for patients requiring renal and respiratory
support within Scotland compares favourably with published studies and
shows minimal variation in spite of considerable differences in dialysis
activity. Lastly, the unique opportunity offered by collaboration between
two national databases, ourselves and the Scottish Renal Registry & Audit
System, has allowed us to demonstrate the very low rate of chronic renal
support required in such patients unless there is evidence of previous
chronic renal impairment. This work has relied considerably on the data
validation performed by Sandra Donaldson who will resign her current
part-time post at the end of this year.
After some technical hitches and an unscheduled break for lunch, the
Peter Andrews 'team' demonstrated the ultimate in automatic cardiovascular
and ICP data collection which he proposes to use to audit the relationship
between variations in management, cardiovascular instability and ultimate
outcome across the four centres which take neurosurgical admissions.
Making a Frank Sinatra comeback, Fiona reviewed the temporal variations
in ICU workload across the Scottish ICUs as a whole and thereafter went
on to examine inter-unit variations in bed occupancy, length of stay
and rate of active intervention. This work forms the basis for any ICU
needs assessment as it includes information which can be used to assess
the extent to which pressure on ICU beds can be relieved by increasing
HDU capacity. This served as an introduction to the subsequent presentations
by Stan
Murray (ably assisted by John McFariane) who reviewed ICU bed needs
in Glasgow and the assessment of HDU bed requirement in Ninewells presented
by Professor lain Ledingham. The work from Glasgow relied on a combination
of our own audit data and an episodic assessment of ICU refusals. The
HDU assessment involved a comprehensive survey of inpatients to assess
the proportion who met HDU criteria set by the DOH Guidelines. The number
of HDU beds calculated from this assessment was lower than that which
had been previously suggested and is broadly in line with the ratio of
ICU:HDU beds which can be derived from surveys performed within GGHB
i.e., approximately 1:2. The relevance of this area of work relates to
discussions we have had with the Scottish Office on re-focussing the
audit to deliver information on the relationship between HDU and ICU
bed provision and the impact of ICU refusals. This latter issue was reviewed
with remarkable clarity and brevity by Malcolm Booth.
An enticing presentation of our sister organisation's
intentions for future development in England & Wales, given by
Dr Kathy Rowan, highlighted the opportunities that will increasingly
arise for co-operation between
us. This was well received by all except John Kinselia as he had to suffer
presentation of the four studies which have been short-listed for funding
to study aspects of pulmonary
artery catheter use and outcome. We want to make it quite clear that
rumours of Scottish paranoia are groundless. However, we remain perplexed
that our track record in this area was insufficient to allow our research
proposal to reach the short list.
Brian Millar, who has been a regular participant in our Audit Meetings,
outlined the future software developments which are anticipated. These
involve establishment of the Bed Bureau in Glasgow by the turn of the
year and, after a one year appraisal of its functionality, the option
of extending it to the West of Scotland and the rest of the Scottish
hinterland. Connectivity of the system with both ICU monitoring and laboratory
equipment, and with the hospital PAS system is anticipated as a natural
development.
Things do not always go as planned to paraphrase Robert Burns. On this
occasion an outstanding contribution by Dr Howie required to be omitted
due to the constraints of time (or completely inadequate planning, depending
which way you look at it). This should have allowed discussion of the
options which exist for future funding and clinical emphasis of the Audit.
FN. MacKirdy
J.C. Howie
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South-East Scotland ITU Group
The SESITU Group has had another full and productive year.
The group encompasses all consultant clinicians working in adult and
paediatric intensive care in this part of the world, namely:- Borders
General Hospital, Meirose; Queen Margaret Hospital, Dunfermline; Royal
Infirmary of Edinburgh; St John's Hospital at Livingston; the Sick Kids,
Edinburgh; and the Western General Hospital, Edinburgh. We have also
seen a growth in the number of interested trainees attending (which is
very welcome). Our meetings rotate round all the different hospitals
and, on the whole, have been very well attended.
Nineteen ninety eight was kicked off by the Western team who put on
a combined presentation with the neurosurgeons on the old chestnut of
Subarachnoid Haemorrhage. Dr Carol Macmillan, ITU fellow, also presented
her work on MR in Acute Brain Injury. Both presentations were very well
received. The Sick Kids team presented on the topic of lntra Medullary
Fluid Resuscitation, amongst other things. St John's presented an interesting
case of acute renal failure which was followed by Dr Liam Plant's (Consultant
Nephrologist, RIE) excellent Consideration of the Management of Acute
Renal Failure. The Borders team presented 4 cases of The HELLP Syndrome/
or Was It Pre-eciampsia?/ or Was It SLE?/ or Was It ITP? The Fife team
presented a case of atypical pneumonia which turned out to be a herpetic
pneumonitis but, initially, had the team foxed by a false positive TB
result. This led to an interesting and practical discussion on the dangers
of bronchoscope contamination. Finally, the RIE team put on a double
bill in the form of two debates on the subjects of This House Believes
in the Use of Albumin and This House Believes in the Use of Nitric Oxide
with, as can be imagined, lively debates ensuing.
The new office bearers of the group were also announced at this meeting:-
President - Dr Patrick Armstrong, StJohn's Hospital, Livingston
Secretary - Dr Alistair Lee, Royal Infirmary
of Edinburgh
Treasurer -
Dr Alasdair Mackenzie, Queen Margaret Hospital, Dunfermline.
M. Fried
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Glasgow and west of Scotlant Intensive Care Society
In the first meeting of the session Dr Richard Griffiths of Whiston
Hospital, Liverpool addressed the society on aspects of nutritional support
in the critically ill patient with particular emphasis on the use of
Glutamine and other immuno-enhancing preparations. This was particularly
well received by the large multidisciplinary audience.
Future meetings arranged include the usual registrar's presentation
evening and a proposed meeting on the Albumin controversy. Dates are
yet to be confirmed.
It is hoped that a proposal based on needs assessment will bring an
extra 4 ICU beds overall to Glasgow. There remains uncertainty as to
the distribution of beds within the city, pending trust reconfiguration.
The Committee for this year is:-
Dr Jim Dougall, Chairman
Dr Alan Davidson, Secretary
Dr Malcolm Booth, Treasurer
Dr Roger White
Dr Angus McKee
The society would like to extend a welcome to individuals of all disciplines
involved in the care of the critically ill.
J.R. Dougall
J.A. Davidson
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Consultant sessions in intensive care in Scotland
A survey of predicted requirement over the next five years
Early in 1998 the SICS Council attempted to estimate the number of consultant
sessions in Intensive Care Medicine likely to become available over the
next five years. A questionnaire was sent to all units on the SICS database.
Twenty-six units were contacted and all responded. The main responses
were:-
Number of ICU beds:
3 beds - 2 units; 4 beds - 9 units; 5 beds -
6 units; 6 beds - 2 units; >6
beds - 7 units
Number of consultants with ICU sessions:
5 consultants - 16 units; 6 consultants - 4 units; >6
consultants - 6 units, including 2 smaller units where the ICU cover
is shared with
theatre cover
Number of ICU consultant sessions:
The vast majority of units had 10 daytime sessions
per week. These were mainly dedicated to the ICU but in a few instances
were shared with other
cover, e.g. emergency theatre. Some larger units had >10 daytime sessions
and specific out of hours sessions.
In the NEXT FIVE YEARS there are likely to be:
1 ) An increase in the number of ICU Consultant sessions:
7 units planned to increase the number of consultant posts or the number
of sessions for the existing consultants. This amounted to a planned
increase of up to 20 sessions.
2) ICU consultant retirements: 8 retirements (mainly 2 sessions each)
= total of 16 sessions
3) ICU consultants considering relinquishing ICU sessions: Up to 10
consultants may relinquish their sessions. Again this was mainly 2 each,
giving a further 20 sessions.
There are therefore a definite 16 sessions becoming available due to
retirements. Planned expansion will possibly generate a further 20 sessions,
while consultants considering relinquishing ICU commitment may lead to
a further 20 sessions.
Most consultants at present work 2 fixed ICU sessions per week (plus
on call), although this pattern may change with the advent of specialist
trained intensivists. On the basis of the present average of 2 ICU sessions
per consultant, a bare minimum of 8 consultants would be required over
the next 5 years, but the best estimate may be up to 28, working a total
of 56 sessions.
At present there are only 6 trainees on Intensive Care Medicine specialist
registrar training programmes in Scotland, each of 2 years duration.
This would generate 15 trained intensivists over 5 years. To fill available
ICU sessions these individuals would need to work up to 4 daytime sessions
per week each. However, it is more likely that a mixture of specialist
intensivists and consultant anaesthetists with ICU interest will be appointed,
working between 2 and 4 daytime sessions per week each.
Many thanks to all units. More detailed results are available from the
SICS council.
A.F Mackenzie
LS. Grant
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The President
It has been another year of progress for the Society. We have been involved
in running courses in collaboration with the Scottish Ambulance Service
(Transport of the Critically 111), and with the Royal College of Physicians
and Surgeons of Glasgow (MRCS), as well as continuing to run Intensive
Care Courses, most recently in Aberdeen. There has been a suggestion
that we should organise a study day to provide updates for consultants.
If this is to be undertaken, we would expect to cast our net for speakers
outwith Scotland.
It is anticipated that the Scottish Parliament
will take a keen interest in Health. It is therefore important that
Intensive Care creates clear
lines of communication to provide appropriate advice. While it might
be preferable for Intensive Care to be represented in its own right,
I do not believe such an option will be on offer. 1 have therefore had
preliminary discussions with the Standing Committee of the Royal College
of Anaesthetists in Scotland to identify the best means by which this
can be organised and, in addition, we have been invited by the Scottish
Society of Anaesthetists to send a representative to their council meetings.
We will, as at present, retain direct communications with the Scottish
Office, as we have a national database which is a unique source of information.
At this time it is not clear how the amalgamation of trusts and the Acute
Services Review's "big idea" of clinical networks will impact
on the delivery of acute medicine. It is crucial that this society succeeds
in placing Intensive Care at the heart of the debate. To do this, our
lines of communication and our control of information will be crucial.
At the time of writing, the national audit has had funding extended
from December 1998 till the end of March 1999 to allow consideration
of a further submission for funding a commissioned project for a period
of approximately 2 years. It has been emphasised that, while there is
great satisfaction with the current audit, more of the same will not
be sufficient to attract ongoing funding. We have demonstrated that there
is not a problem with intensive care! Consequently, while we will continue
to collect information on severity of illness, there will be less emphasis
on overall clinical performance and greater emphasis on attempting to
examine outcomes in discrete patient groups. This we have already done
for patients having prolonged periods of intensive care, and those requiring
combined renal and respiratory support. At present we are in discussion
with Zeneca to support a study of patients who develop ARDS. We will
attempt to provide more information on the impact of discrete processes
in Intensive Care. This could involve simple randomisation in selected
hospitals where there was no clear-cut evidence or preference for a specific
choice of therapeutic intervention (eg nutritional additives thought
to improve immune competence). Outcomes would be mortality, corrected
for severity of illness and ICU and hospital length of stay as currently
collected. We hope to be able to provide benchmarking of ICU length of
stay as a result of work currently being done with Mr John Norrie at
the Robertson Centre in Glasgow University. We are also examining the
extent to which we can develop more meaningful diagnostic categories,
document the impact of ICU refusals, model ICU need in discrete areas,
and contribute to the assessment of HDU need.
One of the most satisfying consequences of our expanding commitments
is that all members of council become involved. And on the subject of
involvement and commitment-The 1999 AGM will see the retirement of lan
Grant from formal council membership, though he may continue to be involved
in an advisory role, as he remains a council member of the ICS. [an has
made a unique contribution to the development of the society, culminating
in his period as President. When will we see his like again? I'm trying
lan, but you're a hard act to follow.
J.C. Howie
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