Department of Perioperative and Critical Care Freeman Hospital Newcastle upon Tyne NE7 7DN United Kingdom
joe.cosgrove@nuth.nhs.uk
Dr Cosgrove graduated from the University of Newcastle upon Tyne in 1988 and began his career in Anaesthesia and Intensive Care Medicine at the then Sunderland General Hospital (now Sunderland Royal Hospitals) in 1991. Thereafter (part through chance and part through Sir Kenneth Calman and conversion of Registrars to Specialist Registrars) he has remained in the North-East aside from 12-months as a Senior Fellow in Anaesthesia and Intensive Care in New South Wales (Newcastle; inevitably!) He was appointed to his current post in 2000 where he has been Intercollegiate Board Tutor and is now Critical Care Outreach lead, with a developing interest in pre-emptive discussions about intensive care admission. He is also a Member of the Board of Examiners of the Royal College of Anaesthetists and has recently been a member of the CCrISP Steering Committee, RCS Eng. (completing the second re-write of the course in September 2010.) Other medical interests include Events Medicine: he is Chair of the Medical Advisory Group for Durham County Cricket Club and adviser to the England and Wales Cricket Board on medical contingency and major incident planning for international cricket matches.
Abstract: Live-related kidney donors are increasingly contributing to renal transplantation. In an attempt to match demand, the technique of live-donor nephrectomy has been developed and refined. Between 2002 and 2007 119 laparoscopic live-donor nephrectomies were performed within our unit. No cases were converted to open and the average hospital stay was 4 days. Three patients required blood transfusion and complications directly attributable to surgery occurred in seven patients. Five patients developed pulmonary oedema and required non-invasive respiratory support in a critical care environment, prompting review of our perioperative management.
We therefore present a review of the history of renal transplantation and our peri-operative management, balancing the evidence of other centres against our clinical experience in order to provide a template for perioperative care with specific reference to respiratory and cardiovascular management when considering the effects of pneumoperitoneum and fluid balance.
Abstract: To determine whether cardiac arrest calls, the proportion of adult patients admitted to intensive care after CPR and their associated mortalities were reduced, in a four year period after the introduction of a 24/7 Critical Care Outreach Service and MEWS (Modified Early Warning System) Charts.
Abstract: National Confidential Enquiry into Patient Outcome and Death guidelines for urgent surgery recommend a fully staffed emergency operating theatre and restriction of 'after-midnight' operating to immediate life-, limb- or organ-threatening conditions. Audit performed in our institution demonstrated significant decreases in waiting times for urgent surgery and an increased seniority of medical care associated with overnight pre-operative assessment of patients by anaesthetic trainees. Nevertheless, urgent cases continued to be delayed unnecessarily. A classification of delays was developed from existing guidelines and their incidence was audited. The results were disseminated to involved directorates. A repeat of the audit demonstrated a significant decrease in delays (p = 0.001), a significant increase in the availability of surgeons (p = 0.001) and a significant decrease in the median waiting time for urgent surgery compared to the first audit cycle and a previous standard (p < 0.01). We conclude that auditing delays and disseminating the results of the audit significantly decreases delays and median waiting times for urgent surgery because of improved surgical availability.
Abstract: Drotrecogin alfa has been shown to reduce mortality in severe sepsis. However, it remains unlicensed for use in patients with previous liver transplantation. We report its use in such a case. Prior to administration a risk benefit analysis was performed in line with General Medical Council recommendations. This included being satisfied that no appropriately licensed alternative would better serve the patient's needs and that sufficient evidence existed to demonstrate the safety and efficacy of the drug. Responsibility was taken for prescription, monitoring and follow up. The process was carefully documented and the patient recovered fully with no adverse effects. To date the only published data on the use of drotrecogin alpha in transplant recipients is a case series of three patients. Further published data may encourage review of the licence.
Abstract: Acute renal failure can occur following major surgery. Predisposing factors include massive haemorrhage, sepsis, diabetes, hypertension, cardiac disease, peripheral vascular disease, chronic renal impairment and age. Understanding epidemiology, aetiology and pathophysiology can aid effective diagnosis and management. A consensus definition for acute renal failure has recently been developed. It relates to deteriorating urine output, serum creatinine and glomerular filtration rate. In the surgical patient, precipitants are often pre-renal, although intrinsic damage and obstructed urine flow can occur. Worsening renal function results in distal organ damage. Acute renal failure is a marker of disease severity, carrying a poor prognosis if associated with deteriorating respiratory and cardiovascular function. Acute renal failure in the critically ill surgical patient exerts a massive impact on the evolution of complications and prognosis. Management relates to treating life-threatening problems, maintaining effective ventilation and circulation, removal (or reduction) of nephrotoxins and, where appropriate, establishing either renal replacement therapy or palliative care.
Abstract: Noncardiogenic pulmonary edema in liver transplant recipients is usually secondary to TRALI (transfusion related acute lung injury) or liver ischemic-reperfusion injury. If persistent, the resultant hypoxemia is associated with increased ventilator days, prolonged length of stay (intensive care and hospital) and increased 28-day mortality. Ventilation strategies for the management of hypoxemia in acute lung injury include moderate to high levels of PEEP (positive and expiratory pressure) and prone ventilation (PV). Such strategies have theoretical adverse effects on graft perfusion. Evidence does however exist to demonstrate that maintenance of cardiac output and correct positioning of the prone patient to allow abdominal excursion can negate the deleterious effects of PEEP and PV. A liver transplant recipient became profoundly hypoxemic on our intensive care unit following the onset of noncardiogenic pulmonary edema. A risk-benefit assessment performed at the time deemed that the potential adverse effects of PEEP and PV were outweighed by the life-threatening nature of hypoxemia. The patient's condition improved following prone positioning and application of PEEP (10-15 cm H(2)O). We conclude that such ventilation strategies are appropriate in hypoxemic liver transplant recipients if an appropriate risk-benefit assessment is performed.
Abstract: Understanding basic pathophysiological principles underpins the practice of many healthcare workers, particularly in a critical care setting. Undergraduate curricula have the potential to separate physiology teaching from clinical contexts, making understanding difficult. We therefore assessed the use of analogous imagery as an aid to understanding. Two groups of first year physiotherapy students were randomly assigned to receive either a control lecture (oxygen delivery and hypoxaemia) or a study lecture (control lecture plus images of a train set delivering rocks: an analogy to oxygen delivery.) Qualitative assessment of the lectures showed a significant (p < 0.001) improvement in understanding by the study group, and increased the proportion of students that found the lecture 'interesting and stimulating' (p = 0.01). Quantitative assessment demonstrated a significant increase in the multiple choice questionnaire marks of the study group (p = 0.03). In conclusion, analogous imagery can significantly increase the understanding of this physiological concept.
Abstract: radical cystectomy can be associated with significant occult gastrointestinal
ischaemia, delaying recovery of bowel function. Perioperative
cardiovascular optimisation (e.g. via the oesophageal Doppler)
can minimise this.
To determine whether cardiovascular optimisation facilitated
early return of bowel function after major cystectomy via a prospective,
randomised, controlled trial.
METHODS: Patients underwent standard anaesthesia and insertion
of oesophageal Doppler (blinded to the anaesthetist.) Intravenous
fluids were administered at the discretion of the anaesthetist and
the trial group received additional intravenous colloid (from a researcher)
guided by haemodynamic measurements (stroke volume
(SV) and corrected flow time (FTc).)
Primary outcomes: ileus (’absence of bowel sounds with non
painful abdominal distension’), flatus, bowel opening, nausea and
vomiting (6, 24, 48-hours post-op.)
Secondary outcomes: total intravenous fluids administered (ml/
kg/hr), hourly fluid (ml/kg.)
Categorical data compared via X2-test; other outcomes via the
unpaired t-test; p <0.05 regarded as significant.
RESULTS: Sixty-six patients (control, n=34; trial n=32.) There
was a significant reduction in gastrointestinal complications in the trial
group (table 1) who received significantly greater volumes of intravenous
fluid in the first hour of surgery (table 2.)
CONCLUSIONS: Cardiovascular optimisation using the oesophageal
Doppler monitoring reduces gastrointestinal complications
after radical cystectomy and is associated with significant increases in
intravenous fluid administration in the first hour of surgery.
Abstract: Patients with acute kidney injury (AKI) and chronic kidney disease have poor intensive care outcomes particularly when cardio-respiratory arrest and cardiopulmonary resuscitation (CPR) contribute to severity of illness1, 2. In 2001 when a Critical Care Outreach Service was first introduced to our hospital, data demonstrated that 68% of cardiac arrest calls in our hospital were from the renal unit (Newcastle upon Tyne Hospitals NHS Foundation Trust Clinical Audit)3. Ward nursing staff subsequently underwent “patient at-risk” training and in 2005 Modified Early Warning System (MEWS) charts and a “seven-day” ward-based consultant physician (devoid of other commitments 0800-1800) were introduced to the renal unit3-6.
To monitor the effectiveness of such changes it was necessary for renal and intensive care medicine (ICM) to audit clinical measures and outcomes. Two three-year periods before and after changes in consultant working practise (2002-04 and 2006-08) were compared. Data (2002-04) was collected from a locally installed ICM database and (2006-08) from the Intensive Care National Audit and Research Network Case Mix Programme (ICNARC-CMP.) Primary measures were admissions to the renal unit and intensive care unit (ICU), renal unit admissions to ICU, cardiac arrests calls per renal unit admission, APACHE II scores on ICU admission and ICU mortality. Secondary outcomes were age, sex, in-hospital mortalities (ICU admissions and all renal unit admissions) and CPR prior to ICU admission. Cardiac arrests, mortality rates and emergency admissions (from the renal unit) were compared with the X2 test; other outcomes via Mann-Whitney U-test for non-parametric data. A p value <0.05 was regarded as significant.
In the first audit period there were 2981 admissions to the renal unit and 2328 total admissions to the ICU. In the second audit cycle renal unit admissions increased to 3297 and ICU admissions to 3434 patients; this was associated with a non-significant increase in renal medicine patients admitted to ICU (4.3% of ICU admissions (n=117) vs. 5% of ICU admissions (n=147), p=0.06), cardiac arrest calls on the renal unit were significantly reduced (89 vs. 46, p<0.0001.) Additionally ICU mortality (35% vs. 25 %, p=0.01), in-hospital mortality (58% vs. 39%, p<0.0001) and median APACHE II scores on ICU admission (26 vs. 23, p=0.02) of patients admitted from the renal unit were all significantly reduced. There was also a significant increase in female patients (p=0.03.) There were no significant differences between all other measures.
Introducing a dedicated ward-based, consultant led service significantly reduced the mortality and severity of illness of ICU patients admitted from the renal unit.
Abstract: Patients with acute kidney injury (AKI) and chronic kidney disease have poor intensive care outcomes particularly when cardio-respiratory arrest and cardiopulmonary resuscitation (CPR) prior to intensive care admission contribute to severity of illness1, 2. In 2001 68% of cardiac arrest calls in our hospital were from the renal unit (Newcastle upon Tyne Hospitals NHS Foundation Trust Clinical Audit.) At this time Critical Care Outreach teams were introduced to improve early recognition of at-risk patients and ward nursing staff underwent “patient at-risk” training. Data collection and analysis of such data via clinical audit was also being encouraged as a means of determining and improving intensive care outcomes3. In 2006 Modified Early Warning System (MEWS) charts and a “seven-day” ward-based consultant physician (devoid of other commitments 0800-1800) were introduced to the renal unit3-6.
To monitor such changes it was necessary for renal and intensive care medicine (ICM) to audit clinical measures and outcomes in order to gauge their effectiveness on patient care. Two three-year periods before and after changes in consultant working practise (2002-04 and 2006-08) were therefore compared. Data (2002-04) was collected from a locally installed ICM database and (2006-08) from the Intensive Care National Audit and Research Network Case Mix Programme (ICNARC-CMP.) Primary measures were admissions to the renal unit and intensive care unit (ICU), renal unit admissions to ICU, cardiac arrests calls per renal unit admission, APACHE II scores on ICU admission and ICU mortality. Secondary outcomes were age, sex, in-hospital mortalities (ICU admissions and all renal unit admissions) and CPR prior to ICU admission. Cardiac arrests, mortality rates and emergency admissions (from the renal unit) were compared with the X2 test; other outcomes via Mann-Whitney U-test for non-parametric data. A p value <0.05 was regarded as significant.
In the first audit period there were 2981 admissions to the renal unit and 2328 total admissions to the ICU. In the second audit cycle renal unit admissions increased to 3297 and ICU admissions to 3434 patients; this was associated with a non-significant increase in renal medicine patients admitted to ICU (4.3% of ICU admissions (n=117) vs. 5% of ICU admissions (n=147), p=0.06), cardiac arrest calls on the renal unit were significantly reduced (89 vs. 46, p<0.0001.) Additionally ICU mortality (35% vs. 25 %, p=0.01), in-hospital mortality (58% vs. 39%, p<0.0001) and median APACHE II scores on ICU admission (26 vs. 23, p=0.02) of patients admitted from the renal unit were all significantly reduced. There was also a significant increase in female patients (p=0.03.) There were no significant differences between all other measures.
Introducing a dedicated ward-based, consultant led service significantly reduced the mortality and severity of illness of ICU patients admitted from the renal unit.
