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Objective: To determine the pharmacokinetic profile of ciprofloxacin 20 mg/kg per day (10 mg/kg administered intravenously 12 hourly) in paediatric patients with severe sepsis. Design: Open and prospective. Setting: Tertiary referral multi-disciplinary ICU. Patients: Twenty patients (two groups – group A: 3 months–1 year; group B 1–5 years). Interventions: Timed blood samples were taken for pharmacokinetics after the first dose (D0), as well as day 2 (D2) and then between days 6–8. Measurements and results: Ciprofloxacin serum levels were measured by high performance liquid chromatograghy. Demographic and clinical data and all adverse events were noted. Standard pharmacokinetic variables were calculated by non-compartmental methods. Peak concentrations (Cmax) for group A were D0 6.1±1.2 mg/l, D2 9.0±1.8 mg/l and D7 5.8±1.3 mg/l and, for group B, 7.4±1.3 mg/l, 7.8±1.6 mg/l and 6.4±1.3 mg/l, respectively, for the study periods. Concentration 12 h after the start of infusion (Cmin) for all periods were 0.2 mg/l or less. Areas under the curve (AUC, 12 h) were group A: 15.6±1.3, 19.2±1.63 and 14.1±1.4 mg/h per l, and group B: 15.9±1.3, 18.0±1.7 and 13.2±1.26 mg/h per l. One patient presenting with seizures, initially controlled, had another convulsion and a further patient developed seizures whilst on ciprofloxacin. Cmax in these patients were higher than the average Cmax. The convulsions of both patients were easily controlled. No other drug-related serious adverse events occurred. No arthropathy was noted. Three patients died of their underlying disease. Conclusions: There was no accumulation of drug even after 7 days of administration. Our Cmax and AUC were lower than that achieved in a similar adult pharmacokinetic study. To achieve end points of area under the inhibitory curve (AUIC) of 100–150 mg/h per l, 10 mg/kg ciprofloxacin eight hourly would be required for some resistant ICU organisms. [ABSTRACT FROM AUTHOR]

More than half of all global maternal deaths occur in Africa. A large percentage of these deaths are preventable, and lack of access to adequate critical care facilities is a contributing factor. There are limited published data on the clinical and management challenges presented by the critically ill obstetric patient admitted to the intensive care unit in our setting, and more data are required in order to better define the critical care needs of this group of patients. [ABSTRACT FROM AUTHOR]

Background: In South Africa (SA), administrators and intensive care practitioners are faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience the consequences of limited resources daily. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are routinely necessary in SA, particularly in the publicly funded health sector., Purpose: The purpose of this guideline is to utilise the relevant recommendations of the associated consensus meeting document and other internationally accepted principles to develop a guideline to inform frontline triage policy and ensure the best utilisation of adult intensive care in SA, while maintaining the fair distribution of available resources., Recommendations: An overall conceptual framework for the triage process was developed. The components of the framework were developed on the basis that patients should be admitted preferentially when the likely incremental medical benefit derived from ICU admission justifies admission. An estimate of likely resource use should also form part of the triage decision, with those patients requiring relatively less resources to achieve substantial benefit receiving priority for admission. Thus, the triage system should maximise the benefits obtained from ICU resources available for the community. Where possible, practical examples of what the consensus group agreed would be considered appropriate practice under specified South African circumstances were provided, to assist clinicians with practical decision-making. It must be stressed that this guideline is not intended to be prescriptive for individual hospital or regional practice, and hospitals and regions are encouraged to develop specified local guidelines with locally relevant examples. The guideline should be reviewed and revised if appropriate within 5 years., Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, this guideline has been developed to guide policy-making and assist frontline triage decision-making in SA. This document is not a complete plan for quality practice, but rather a template to support frontline clinicians, guide administrators and inform the public regarding appropriate triage decision-making., Competing Interests: Conflicts of interest: GMJ: Steering committee member and international instructor of the Basic Assessment and Support in Intensive Care (BASIC) educational collaboration, that received unrestricted educational grants from Maquet, Hamilton Medical and Draeger. LRM: Immediate Vice President of the Critical Care Society of Southern Africa. DG, AA, SC, RW, VKWL, EH, AL, IJ, SM, ST, GAR, CM, BE, BL, KA, FP: The remaining authors have stated that they do not have any potential conflicts of interest., (Copyright © 2019, Joynt et al. Copyright of published material remains in the Authors’ name. This allows authors to use their work for their own non-commercial purposes without seeking permission from the Publisher, subject to properly acknowledging the Journal as the original place of publication.)

Background: In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector., Purpose: The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care., Recommendations: In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years., Conclusion: In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources., (Copyright © 2019, Joynt et al. Copyright of published material remains in the Authors’ name. This allows authors to use their work for their own non-commercial purposes without seeking permission from the Publisher, subject to properly acknowledging the Journal as the original place of publication.)

Objective: To evaluate, in critically ill children, the safety and effectiveness of routine central venous catheterisations (CVCs) performed by residents from all disciplines., Design: Prospective audit of all CVCs over a 24-month period., Setting: Multidisciplinary intensive care unit at Baragwanath Hospital, Soweto., Patients: All critically ill patients 12 years of age or younger requiring CVC. All percutaneous sites (subclavian, internal jugular and femoral) were used; these were selected by the attending doctor and not influenced by the audit., Results: There were 272 catheterisation attempts, of which 241 (88.6%) were successful. Patient age and size but not disease severity influenced incidences of both catheterisation failure and minor bleeding. The latter was the commonest early complication, occurring in 63 (23.2%) successful catheterisations. There were 7 major complications-3 pneumothoraces, 2 tachyarrhythmias and 2 major bleeds, all with subclavian vein catheterisation. Catheter-related infections (CRIs) occurred in 85 (51.2%) of 166 lines and catheter-related septicaemia (CRS) in 10 (5.7%) of 175 lines where there were sufficient data for evaluation. No patient or line factor, including duration of insertion, influenced CRI or CRS. In CRI, Staphylococcus epidermidis was the commonest organism. Other common CRI isolates were Enterococcus faecalis, Klebsiella spp. and Candida albicans. Six different organisms were implicated in CRS., Conclusions: CVC is a safe procedure with a high success rate. The femoral vein is the recommended percutaneous site of choice as it carries no great risk of sepsis and does not expose the patient to the hazard of intrathoracic complications.

To test the expanded definition of acute lung injury (ALI), we prospectively, over a period of 8 months, studied all adult ICU admissions who fitted the definition. Our study consisted of 83 patients with the adult respiratory distress syndrome (ARDS) and 60 with mild to moderate ALI. Sepsis and trauma were the most common diagnoses on admission. The overall mortality rate was 45 percent for ARDS and 38 percent in the other group. Mortality rose significantly with associated other organ failure, the incidence of which was as follows: hepatic, 39 percent; cardiac, 38 percent; hematologic, 22 percent; renal, 21 percent; neurologic, 5 percent. Sepsis syndrome eventually occurred in 73 percent and septic shock in 38 percent of all cases of ALI. We found the expanded definition a useful grading system and consider this definition of ARDS to be currently the best. There are, however, problems with the determination of lung compliance, the effect of inverse ratio ventilation, and the lack of consensus in defining other organ failure.