Cricothyroidotomy is infrequently performed in the intensive care unit but may be a lifesaving procedure. The aim of this study was to determine the number of attempts required by trainees to gain adequate skills for a successful cricothyroidotomy (defined as lung inflation <60 seconds). The effect of training on time to completion of cricothyroidotomy was also studied. After viewing a demonstration video on the procedure, each participant attempted cricothyroidotomy five times consecutively on a manikin with a pre-assembled Melker cricothyroidotomy kit. Time from 'skin' palpation to 'lung' inflation was recorded for 30 participants. Time to completion of cricothyroidotomy decreased over consecutive attempts within each participant (F4df=39.6; P <0.001) and between participant variability in times recorded at each attempt also decreased (P=0.04). Overall improvement in time to completion was seen even between the fourth and fifth attempts (mean difference -6.3 seconds; P <0.001). All participants were successful by the fifth attempt, by which stage all but two had been successful on two consecutive attempts. Age, years of postgraduate practice and level of seniority appeared to be associated with earlier success. Consecutive attempts on a manikin led to an improvement in the time to completion of cricothyroidotomy and rate of a successful outcome (<60 seconds). We recommend that clinicians undergo at least five training attempts on a manikin to gain proficiency in cricothyroidotomy.

Objective To describe the epidemiology of 2009 A/H1N1 influenza in critically ill pregnant women.Design Population based cohort study.Setting All intensive care units in Australia and New Zealand.Participants All women with 2009 H1N1 influenza who were pregnant or recently post partum and admitted to an intensive care unit in Australia or New Zealand between 1 June and 31 August 2009.Main outcome measures Maternal and neonatal mortality and morbidity.Results 64 pregnant or postpartum women admitted to an intensive care unit had confirmed 2009 H1N1 influenza. Compared with non-pregnant women of childbearing age, pregnant or postpartum women with 2009 H1N1 influenza were at increased risk of admission to an intensive care unit (relative risk 7.4, 95% confidence interval 5.5 to 10.0). This risk was 13-fold greater (13.2, 9.6 to 18.3) for women at 20 or more weeks' gestation. At the time of admission to an intensive care unit, 22 women (34%) were post partum and two had miscarried. 14 women (22%) gave birth during their stay in intensive care and 26 (41%) were discharged from an intensive care unit with ongoing pregnancy. All subsequently delivered. 44 women (69%) were mechanically ventilated. Of these, nine (14%) were treated with extracorporeal membrane oxygenation. Seven women (11%) died. Of 60 births after 20 weeks' gestation, four were stillbirths and three were infant deaths. 22 (39%) of the liveborn babies were preterm and 32 (57%) were admitted to a neonatal intensive care unit. Of 20 babies tested, two were positive for the 2009 H1N1 virus.Conclusions Pregnancy is a risk factor for critical illness related to 2009 H1N1 influenza, which causes maternal and neonatal morbidity and mortality.

We compared three different cricothyroidotomy techniques on a cadaveric porcine airway model to determine the most rapid, successful and safe method in emergency situations. In this observational comparative bench-test, surgical or scalpel cricothyroidotomy (ST), Cook Melker Cricothyrotomy Kit (CM) and Portex Cricothyroidotomy Kit (PCK) were evaluated. After a familiarisation program, four operators performed five procedures using each of the techniques. A dissected pig airway was housed in an airway training manikin. Time to successful completion of the procedure, complications and anatomical variations in the pig larynx were recorded. A patent airway was established in 20 of 20 (100%) attempts with CM technique, 11 of 20 (55%) with ST and six of 20 (30%) with PCK technique. The CM technique was associated with a higher success rate (P <0.001). There was no significant difference (P=0.4) in the median time (interquartile range) taken to achieve a patent airway; CM 50 seconds (40 to 57), ST 47 seconds (41 to 55) and PCK 63 seconds (41 to 150). There was a higher rate of posterior tracheal wall injury with the PCK technique (n=11) and ST technique (n=5). No complications were observed with CM technique. There were no significant anatomical variations in the pig larynxes. We conclude that the CM technique is safe, rapid and has a significantly higher success rate in achieving an artificial airway in this airway model. Overall, all the participants in our study preferred to use this kit in an emergency situation.

Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. Exclusion criteria were: cardiac or oesophageal surgery during current hospitalisation, atrial fibrillation at admission, implanted pacemaker and expected intensive care unit stay of less than 24 hours. Sixty-one patients were included in the study. Eighteen patients (29.5%, confidence interval 18-40) developed atrial fibrillation. Incidence of atrial fibrillation was 4.02 episodes per 100 patient days. Patients who developed atrial fibrillation had higher age (71.3 years vs. 63.2 years, P=0.001), severity of illness (APACHE II 25.4 vs. 20.0, P=0.005) and sepsis at admission (9/18 vs. 9/43, P=0.01). They also had higher in-hospital mortality (Risk ratio 2.7, 95% confidence interval 1.3-5.4). Standardised mortality ratio was higher in patients who developed atrial fibrillation (1.08 vs. 0.63). Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age > 75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.

Heliox, a mix of oxygen and helium, has a number of potential medical applications resulting from its relatively lower density. This paper reviews the physics underlying its utility and considers the evidence for its use. While there are studies that support its role, particularly in patients with exacerbations of asthma and chronic obstructive pulmonary disease (COPD), the data are inconclusive.

BACKGROUND:Diethylene glycol (DEG) is a well-known metabolic and renal toxin usually ingested accidentally as an ethanol substitute or as a contaminant in various medicinals. To date, most poisonings have occurred in third-world countries where early death from renal failure is very common. We report a series of seven patients presenting with epidemic DEG poisoning from a correctional facility with varying degrees of metabolic acidemia and acute renal impairment responding to emergent hemodialysis (HD). Significantly, three patients developed delayed neurologic toxicity which has not been well characterized in the past.CASE SERIES:Seven male patients (age range 19-55) presented over a 36 h period following ingestion of varying quantities of DEG. Initially three patients, ingesting the largest quantities of DEG, presented more than 24 h postingestion with severe metabolic acidemia (pH range 6.8-7.1) and anuric acute renal failure requiring HD. All three remained dialysis-dependent and developed significant cranial neuropathies with bulbar palsy in the second week postingestion. One patient died with cerebral oedema and a progressive encephalopathy. Two further patients presented within 24 h of ingestion with normal renal function and a moderate metabolic acidemia (pH range 7.2-7.28) requiring HD. They remained well. Finally, two further patients presented with a history of trivial DEG ingestion and did not require any therapy. Neurologic signs in the two surviving initial presenters improved over 4-6 months although they remained dialysis-dependent.CONCLUSION:Unrecognized DEG poisoning may present with metabolic acidemia and anuric acute renal failure. Established renal impairment may predict subsequent delayed neurologic toxicity.

A number of European studies have documented the ability of procalcitonin (PCT), a novel inflammatory marker, to discriminate patients with sepsis from those with other causes of systemic inflammatory response syndrome (SIRS). The aim of this study was to assess procalcitonin's performance in an Australian intensive care unit (ICU) setting to examine whether it could discriminate between these two conditions. One hundred and twenty-three consecutive adult ICU patients fulfilling criteria for SIRS were enlisted in the study. Over a period of five days, daily serum PCT and C-reactive protein (CRP) levels were measured. At least two sets of cultures were taken of blood, sputum/broncho-alveolar lavage (BAL) and urine. Other cultures were taken as clinically indicated. Questionnaires to ascertain clinical suspicion of sepsis were prospectively answered by the ICU senior registrars. PCT values were ten times higher in patients with positive blood cultures; CRP values were also significantly higher in the bacteraemic patients. Both PCT and CRP had a good ability to discriminate bacteraemia from non-infectious SIRS, with the area under receiver operating characteristics (ROC) curves for PCT being 0.8 and for CRP being 0.82. However neither PCT or CRP was able to discriminate patients with localized sepsis from those without. Utilizing both tests resulted in a more sensitive screen than either one alone, while PCT was a more accurate diagnostic test for bacteraemia than CRP. The PCT value also differed between those who died in hospital and those who survived. Measurement of PCT alone or in combination with CRP can aid discrimination of septicaemia/bacteriemia with associated SIRS from non-infectious SIRS in an Australian ICU setting.