Fifty consecutive critically ill patients transported between hospitals by a mobile intensive care team were assessed prospectively using a modification of the acute physiology and chronic health evaluation (APACHE H) sickness scoring system. Assessments were made before and after resuscitation, on return to base, and after 24 hours of intensive care.

A physiological sickness scoring system (SS), based on the APACHE II score, has been used to assess outcome from critical illness in 128 patients admitted to a general intensive care unit. Physiological data were collected on each patient from admission until death or discharge from the unit, and survival was recorded as survival to home. The admission SS correctly classified 80.6% of survivors, and 70.4% of non-survivors. Predictive power did not improve with time using the daily SS. However, when the proportional change in SS over time was included in the analysis, predictive power improved; and at day 4, 87.1% of survivors and 75% of non-survivors were correctly classified. At intermediate levels of sickness severity (admission score of 13-18), a reduction in SS of 30% by day 4 reduced the risk of death by 32%; at higher levels (greater than 18) a similar reduction in SS was associated with a 47% reduction in death-risk. Failure to obtain a reduction in score by day 4 was associated with increased risk of death. Survivors consistently showed a greater fall in SS by day 4 than non-survivors. The APACHE score and its modifications provide an accurate, unitary measure of physiological disturbance. Correction of abnormal physiology, and the measurement of responsiveness to therapy are important components in the prediction of outcome from critical illness.

The aims of this study were to investigate the acute cardiovascular response to manual hyperinflation and to determine whether the technique results in haemodynamic compromise in coronary artery surgery subjects in the early post-operative period. A repeated-measures clinical trial involving a single intervention period was conducted. Manual hyperinflation using a two-litre resuscitation circuit was delivered within 5 h of surgery by experienced physiotherapists for a period of 4 min to subjects (n = 30) who had undergone coronary artery surgery. Swan-Ganz catheters and bedside monitoring showed significant changes in heart rate, mean pulmonary artery pressure, central venous pressure and the pulmonary vascular resistance index measured during, or after, manual hyperinflation. These changes in mean pulmonary arterial pressure and central venous pressure may be due to alterations in intrathoracic pressures generated during manual hyperinflation; however, the changes in heart rate and the pulmonary vascular resistance index are not readily explained. We conclude that the use of manual hyperinflation as part of the immediate post-operative physiotherapy management of stable, mechanically ventilated coronary artery surgery patients does produce significant changes in some haemodynamic parameters, but none of the recorded changes were of a magnitude considered to be clinically significant.

Acute cardiogenic pulmonary edema as the first presentation of pheochromocytoma is uncommon and usually rapidly fatal. A 39-yr-old man presented in acute cardiogenic shock with global ventricular dysfunction that required high-dose iv inotrope support and an intraaortic balloon pump assist device. Abdominal imaging to exclude aortic dissection revealed a 6-cm right adrenal mass. Significant myocardial infarction (electrocardiographic changes and elevated cardiac enzymes) contributed to the cardiac decompensation. After withdrawal of inotrope support, 24-h urinary catecholamine levels revealed 2,155 nmol/d (<125) of adrenaline and 7,437 nmol/d (<560) of noradrenaline, confirming a pheochromocytoma. The tumor was successfully removed at laparotomy; however, the patient's course was complicated by a thromboembolic cerebrovascular accident with paraplegia. He recovered cardiac function almost completely within 3 wk of medical therapy alone. Although uncommon, this case highlights the need to consider pheochromocytoma early in the management of unexplained cardiogenic shock.

We have studied the metabolic and hormonal responses to surgery, and the pain scores and analgesic requirements in 24 patients undergoing cholecystectomy, allocated randomly to three groups to receive either general anaesthesia alone, or general anaesthesia with extradural diamorphine 0.1 mg kg-1, or general anaesthesia with extradural somatostatin to a total dose of somatostatin 3 mg. The only significant effect of extradural diamorphine was a decrease in the glucose response to surgery. Somatostatin 3 mg by the extradural route caused a significant increase in the concentration of circulating somatostatin which resulted in a significant decrease in plasma growth hormone and insulin after 60 min of surgery, together with an increase in plasma glycerol concentration. Patients in the diamorphine group required significantly less i.v. analgesia in the postoperative period than the other two groups. Intraoperative somatostatin failed to provide any postoperative analgesia.