Correspondence
afforded them no estimate of the number of patients
whose clinical course was positively influenced through
the use of EWS at ward level and who, as a result, were
not admitted to critical care and did not suffer cardiac
arrest or death. Application of the aforementioned composite end point describes final patient outcome, not only as
a reflection of a given physiological track and trigger
system, but also as a reflection of the nature of the accompanying response algorithm, in addition to all other confounding variations in subsequent clinical management.
The work currently underway by Smith and colleagues8
may lead to a greater degree of accuracy in the tracking of
physiological parameters through the use of electronic data
capture and analysis against a track and trigger algorithm.
Although such electronic data capture helps offset human
error in the calculation of physiology scores, the work in
question is still in its developmental stage and the relevant
practical tools are not likely to be available to the majority
of healthcare professionals in even the near future.
Cuthbertson and Smith also imply that the routine application of physiological track and trigger scoring to all
acute patients generates a significant additional workload.
Work in the late 1990s confirmed that the application of
an aggregate weighted scoring system, with calculation of
a total score, took only 30 s to complete ( personal communication). The time taken to complete an aggregate
score is now significantly less with improved hard copy
ward observation charts incorporating EWS principles in
their primary design. Physiological track and trigger can
be applied to all acute patients with minimal extra effort
for significant potential gain.
Routine measurement of ‘basic observations’ to assist in
assessment of the severity of a patient’s illness and their
clinical progress has been a mainstay of medical and
nursing practice for decades. Indeed, it has been a form of
implicit physiological tracking but without an explicit
‘trigger’. EWS represents a simple refinement to the completion of basic observations by the assignment of
weighted values to time honoured physiological variables
according to their degree of deviation from the norm. A
total score is then calculated and executive action initiated
at an agreed trigger threshold. This trigger threshold is
used to assist inexperienced nursing or medical staff in
securing immediate, more experienced help. The process
enables the implementation of prompt, appropriate customized management plans. These plans are often very
simple in the early stages of physiological deterioration
but at other times significantly more complex and resource
intensive. Such tailored individual patient management
clearly represents high-quality care.
It is notable that the National Institute for Clinical
Excellence (NICE), in its recent (July 2007) definitive guidance on ‘Acutely ill patients in hospital’9 recommend, as a
priority, that ‘physiological track and trigger systems
should be used to monitor all patients in acute hospital settings’. This priority recommendation echoes an exactly
similar priority recommendation made by the National
Confidential Enquiry into Patient Outcome and Death
(NCEPOD) in 2005 in their publication entitled ‘An Acute
Problem’.10 In many acute hospitals in England, the current
use of track and trigger scoring systems facilitates the
prompt summoning of skilled help to the bedside. We
remain convinced that this process enables the ‘high-quality
clinical assessment and judgement by appropriately skilled
and experienced personnel’, as applauded by Cuthbertson
and Smith in their closing comments, to be applied in more
timely fashion than might otherwise have been the case.
R. J. M. Morgan1*
M. M. Wright2
1
Blackpool, UK
2
Great Yarmouth, UK
*E-mail: [email protected]
1
Duckitt R, Buxton-Thomas R, Walker J, et al. Worthing physiological
scoring system: derivation and validation of a physiological early
warning system for medical admissions. An observational,
population-based single-centre study. Br J Anaesth 2007; 98: 769–74
2 Cuthbertson BH, Smith GB. A warning on early warning scores!
Br J Anaesth 2007; 98: 704 – 6
3 Morgan RJM, Williams F, Wright MM. An early warning scoring
system for detecting developing critical illness. Clin Intensive Care
1997; 8: 100
4 Morgan RJM. Outreach critical care—cash for no questions?
Correspondence. Br J Anaesth 2003; 90: 699 – 700
5 Buist MD, Moore GE, Bernard SA, et al. Effects of a medical
emergency team on reduction of incidence of and mortality from
unexpected cardiac arrests in hospital: preliminary study. Br Med J
2002; 324: 387 – 90
6 NHS Modernisation Agency 2003, Progress in Developing
Services—Critical Care Outreach
7 Gao H, McDonnell A, Harrison DA, et al. Systematic review and
evaluation of physiological track and trigger warning systems for
identifying at-risk patients on the ward. Intensive Care Med 2007;
33: 667 – 79
8 Smith GB, Prytherch DR, Schmidt P, et al. Hospital wide physiological surveillance—a new approach to the early identification
and management of the sick patient. Resuscitation 2006; 71:19 –28
9 NICE clinical guideline 50. Acutely ill patients in hospital. July 2007
10 NCEPOD 2005 Report. An Acute Problem!
doi:10.1093/bja/aem286
Hiccup during weaning from mechanical
ventilation: the use of nefopam
Editor—We report the use of nefopam in two cases with
severe hiccup occurring during mechanical ventilation
weaning in neurosurgical patients. The first patient was a
46-yr-old male admitted to intensive care after a subarachnoid haemorrhage with early generalized seizures requiring
sedation and mechanical ventilation. Neurosurgical clipping was performed 24 h after arrival, and an intracranial
748
Correspondence
pressure (ICP) device and an external ventricular shunt
were implanted. I.V. sedation with midazolam and sufentanil and enteral anti-convulsive treatment ( phenytoin
100 mg/8 h) and nimodipine (60 mg/4 h) by nasogastric
tube were started. When sedation was stopped 3 days after
surgery, the patient developed severe hiccup at a frequency
of 20 min21, leading to inefficient mechanical ventilation,
including in pressure support mode. Continuous aspiration in
the naso-gastric tube was unsuccessful. I.V. treatment with
droperidol 0.5 mg and ondansetron 4 mg, used twice, were
ineffective. A slow i.v. infusion of nefopam (40 mg in
10 min) decreased hiccup frequency and stopped it in nearly
10 min. Pressure support ventilation (14 mbar) was then
possible and efficient. During nefopam treatment,
ICP remained stable around 10–15 mm Hg without any
seizure whereas heart rate increased from 79 to 90 beats
min21. Continuous infusion (100 mg per day) of nefopam
was given after the first bolus. Hiccup started again approximately 3 h after the first injection and i.v. administration of
40 mg nefopam was again effective. During the following 2
days, similar episodes were also treated by repeated nefopam
40 mg infusion. Weaning of mechanical ventilation was then
possible without complication.
The second case was a 45-yr-old male with a severe traumatic brain injury 12 yr earlier resulting in left hemiplegia
and chronic hydrocephalus with ventriculo-peritoneal
shunt, who was admitted with septic shock secondary to
severe pneumonia and peritonitis. The peritonitis was
related to small bowel necrosis and surgery for intestinal
resection and removal of the peritoneal part of the ventricular shunt was required. An ICP device was placed on the
first postoperative day. During the ventilation weaning
period, 7 days after surgery, severe hiccup occurred when
the pressure support mode was used. Continuous aspiration
in the naso-gastric tube and increase in pressure support
(up to 20 mbar) were unsuccessful. A slow i.v. infusion of
nefopam (40 mg in 10 min) stopped the hiccup in about
10 min. During nefopam treatment, the ICP remained
unchanged at 15 mm Hg without any seizure, and heart rate
increased from 87 to 101 beats min21. Hiccup started again
approximately 8 h after the first injection, requiring another
i.v. administration of nefopam, 40 mg, once again rapidly
effective. The next day, a similar episode was also treated
by another nefopam 40 mg infusion. Weaning of mechanical ventilation was delayed after a ventriculo-atrial shunt
was placed surgically.
Hiccup has been reported as a frequent problem in
stroke patients or those with ventriculo-peritoneal shunt.1 2
The incidence of hiccup in patients undergoing mechanical ventilation is unknown; however, hiccup during
mechanical ventilation could lead to patient-ventilator
asynchrony. In our patients, the hiccup became an issue
for mechanical ventilation weaning.
In addition to its analgesic effect, nefopam has been
shown to inhibit hiccup in ‘medical’ patients or in the two
first postoperative days among ‘surgical’ patients.3 4 The
originality of our case reports is its use during mechanical
ventilation weaning. A dose – response effect is likely, as
40 mg bolus worked consistently, whereas continuous
infusion did not. We hypothesize that nefopam’s effect
was related to its action on serotoninergic receptors and its
anticholinergic effects.5 Moreover, as hiccup can be linked
with heartbeat,6 the nefopam-induced increase in heart rate
(around 10 beats min21 in both cases) could have
decreased the hiccup frequency and even stopped it. The
use of the nefopam in patients at risk of seizure remains
controversial. We did not see seizures or any change in
ICP in our two neurosurgical patients.
S. Pajot
T. Geeraerts*
P.-E. Leblanc
J. Duranteau
D. Benhamou
Le Kremlin-Bicetre, France
*E-mail: [email protected]
1 Karian JM, Buchheit WA. Intractable hiccup as a complication of
ventriculoperitoneal shunt: case report. Neurosurgery 1980; 7: 283–4
2 Kumar A, Dromerick AW. Intractable hiccups during stroke rehabilitation. Arch Phys Med Rehabil 1998; 79: 697– 9
3 Bilotta F, Rosa G. Nefopam for severe hiccups. N Engl J Med 2000;
343: 1973 – 4
4 Bilotta F, Pietropaoli P, Rosa G. Nefopam for refractory postoperative hiccups. Anesth Analg 2001; 93: 1358– 60
5 Girard P, Coppe MC, Verniers D, Pansart Y, Gillardin JM. Role of
catecholamines and serotonin receptor subtypes in nefopam-induced
antinociception. Pharmacol Res 2006; 54: 195–202
6 Chen BY, Vasilakos K, Boisteanu D, Garma L, Derenne JP,
Whitelaw WA. Linkage of hiccup with heartbeat. J Appl Physiol
2000; 88: 2159 – 65
doi:10.1093/bja/aem287
Tracheal intubation with LMA CTrachTM :
need for cricoid pressure
Editor—Before replacing the intubating laryngeal mask
airway (ILMA) with the LMA CTrachTM (CT) in our predefined algorithm for unexpected difficult airway management,1 we assessed CT performance in morbidly obese
patients and some with an anticipated difficult airway. We
observed that cricoid pressure can be helpful when using
the CT. We report two cases of patients with a difficult
airway, who despite the CT being optimally placed in the
pharynx, required a combination of a Chandy manoeuvre
and external force directly applied over the cricoid cartilage to facilitate tracheal intubation. A difficult airway was
anticipated in the first patient because of a previous laryngeal tumour (the patient refused awake fibreoptic intubation) and in the second patient upper airway examination
revealed a Mallampati grade 3 and 4.0 and 6.5 cm
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