Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision-making and provides recommendations for the resource-limited environment.

Background:The spectrum of illness and long-term outcome of critically ill patients admitted to intensive care units (ICUs) in South Africa remains largely unknown. Objectives: This study was designed to provide data on ICU outcomes and disease burden in public sector ICUs in KwaZuluNatal. The primary objective was to describe 30-day mortality of all patients admitted to participating sites. Secondary objectives included clinical demographics and spectrum of illness amongst these patients, and testing a template to demonstrate feasibility of such data collection. Methods: 30DOS was a multicentre, prospective, observational cohort study conducted over 30 days. An a priori decision was made to report study results separately for adults and paediatric patients. This article reports the results for adult patients. The complete 30-DOS study included 11 ICUs in six hospitals. All adult patients admitted to study ICUs were included. Patients were followed up telephonically by a research assistant. Data on patient demographics, preadmission functional scoring, injury severity scoring, co-morbidities, admission diagnosis/es, organ support, and outcome were collected. Results: A total of 228 adults were included. The majority of admissions (73.7%) occurred on an emergency basis, with 68.4% occurring in the postoperative period. Approximately half were for non-communicable disease (49.6%), followed by trauma (29.0%) and infectious disease (21.5%). There were a total of 59 (25.9%) deaths within the first 30 days after admission. In-ICU mortality was 19.7%. There were 12 (5.3%) in-hospital deaths following discharge and two (0.9%) out-of-hospital deaths. Thirtyday survival was known for 174 (76.3%) admissions with a 33.9% mortality rate. Conclusion: Overall in-ICU mortality was 19.7% with a large trauma burden in a young population. Thirty-day mortality was 33.9%. Information pertaining to patient demographics and spectrum of illness provided novel information to further the understanding of the demand placed on critical care resources within South Africa.

IntroductionThe consequences of excessive endotracheal tube (ETT) cuff pressure are known and have long-term effects; however less attention is placed upon cuff pressure and tube position pre-hospital and in emergency centre. The aim of this study was to evaluate the ETT cuff pressure and tube position on arrival of all patients admitted to the Trauma Unit at Inkosi Albert Luthuli Central Hospital, both from scene and inter-hospital transfers to determine the median cuff-pressure and if there were differences between the two groups.MethodsData from Trauma Unit patients are entered into a prospective; UKZN approved (BE207-09) Trauma Database. Data on 65 admissions between April and December 2014 were reviewed to determine the arrival cuff pressure and tube position. Data captured included patient age, cuff pressure, where and who intubated the patient, and time since intubation to cuff pressure check. Data were analysed by descriptive statistics and Student’s t-test for continuous data.ResultsMost patients had sustained motor vehicle related trauma, with a male predominance. Equal numbers were intubated pre-hospital versus the in-hospital group. Eighty percent of ETT’s were placed in the correct anatomical location, however only 23% of cuff pressures were found to be within the safe pressure limits. ETT cuff pressures were excessive in the pre-hospital ALS group more often than the facility-intubation group (p = 0.042). There were fatal complications related to supra-glottic intubations resulting in aspiration pneumonia, highlighting the need for X-ray confirmation of tube position.ConclusionMost patients, whether intubated on-scene or at hospital have ETT cuff pressures that are excessive, with the potential for ischaemic necrosis of the tracheal mucosa. ETT cuff manometry should be standard of care for all prehospital and in-hospital intubations where the tube will remain in situ for any prolonged period of time. Before inter-facility transfer ETT position should be confirmed radiologically.

Background: Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. Methods: Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. Results:The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037). Conclusion:The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

Renal replacement therapy (RRT) is a scarce and expensive resource in developing countries. [1-3] Critically ill patients in developing countries are at risk for acute kidney injury (AKI) with rhabdomyolysis, sepsis, toxin ingestion or severe metabolic acidosis being common requests for intensive care admission for RRT. [3-6] In South African (SA) intensive care units (ICUs), RRT is commonly undertaken by both intensivists and nephrologists in the ICUs. [4,5] The relative scarcity of RRT in developing countries places a burden on clinicians that have access to this modality of treatment. The need for RRT in patients with acute indications for haemodialysis or ultrafiltration often has to be weighed against the availability of dialysis machines. [3] This difficulty in triage of scarce resources in SA has previously been tested legally in a patient with chronic kidney disease (CKD). [7] Currently, there is no consensus regarding the criteria for the initiation of RRT. There are often multiple reasons, but the indications for type and dose of RRT in SA require further investigation. [4] Our study aimed to examine the utilisation of RRT in ICUs capable of RRT in KwaZulu-Natal (KZN) Province, SA. We analysed the demographics of patients who received RRT, indications for RRT and outcomes (length of stay (LoS), length of ventilation (LoV) and ICU mortality). Methods A prospective observational study was performed to investigate the utilisation of RRT among patients admitted to ICUs in KwaZulu-Natal with respect to indications for initiation, methods and dosing of RRT.