stewart, penny — life and death in the red center

The Intensive Care Unit I Alice Springs Hospital

Life and Death in the Red Centre

Penny Stewart

Alice Springs Hospital Intensive Care Unit

March 2014

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

Different Creatures

The Intensive Care Unit I Alice Springs Hospital

Australia’s Biodiversity – 1 of only 2 developed

countries in the 17 mega diversity countries of the world

Species Australian Species Desert Species

Vertebrates

Frogs 210 42

Reptiles 800 210

Birds 760 230

Mammals 360 95

Invertebrates

Cicadas 202 32

Butterflies 397 92

The Intensive Care Unit I Alice Springs Hospital

A Backpackers Dance with

Death

The Intensive Care Unit I Alice Springs Hospital

Case 1

From Uluru

To Alice

To ECMO

The Intensive Care Unit I Alice Springs Hospital

Case 2

ALICE

And

The

Spider

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Case 3

Another Tourist

Bitten by the Alice BUG

The Intensive Care Unit I Alice Springs Hospital

What is Going On?• potential immuno-modulation by envenomation• apparent late effect• is this primary?• is this synergistic with antibiotics?• is this a new species (all un-identified)?• is this a known species with a novel venom?• how do we progress this?• Is this another creature related mystery from the red

centre?

the moral at the moment…

The Intensive Care Unit I Alice Springs Hospital

“Trust no Spider…”

The Intensive Care Unit I Alice Springs Hospital

Differences in Population

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

Drug reactions

• Severe drug-induced hypersensitivity syndrome with a

shared HLA-B allele causing DRESS in phenytoin

• HLA typing all HLA-B*56:02 as a common allele

>10% of the desert MOB.

The Intensive Care Unit I Alice Springs Hospital

Alcohol

The Intensive Care Unit I Alice Springs Hospital

Statistics

• Age adjusted rates Aboriginal vs. non

Aboriginal:

– Death rate 3.5x higher

– Hospitalization rate 6.5x higher

• Alcohol responsible for:

– 48% of fatal road trauma

– 56% of suicides

The Intensive Care Unit I Alice Springs Hospital

The Grog Story

Reducing the sale of high percentage alcohol, the opening times and the number of alcohol outlets does work.

The Intensive Care Unit I Alice Springs Hospital

Is it the drugs or the life style that makes the difference?

The Intensive Care Unit I Alice Springs Hospital

Population in Northern Territory

The Intensive Care Unit I Alice Springs Hospital

Statistics

• 70% of deaths among Indigenous Australians occur before the age of 65 years

compared with

• 21% of deaths among non- Indigenous Australians.

• Age specific:

– 25–34: 4x

– 35–44: 5x

– 45–54: 6x

The Intensive Care Unit I Alice Springs Hospital

Spending per-Capita vs. Life Expectancy

The Intensive Care Unit I Alice Springs Hospital

Spending per-Capita vs. Life Expectancy: Australia

Australia, non-indigenous

90

80

70

60

50

40

30

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

The Intensive Care Unit I Alice Springs Hospital

Australia, non-indigenous

90

80

70

60

50

40

30

0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Australia, indigenous

Spending per-Capita vs. Life Expectancy: Australia

The Intensive Care Unit I Alice Springs Hospital

Exploring Disease- Diabetes

• prevalence:– 30% indigenous Australians vs. 6% general population

The Intensive Care Unit I Alice Springs Hospital

Exploring Disease- Diabetes

Now explore the age group 20-45 years old:– 18 x more likely to have diabetes– indigenous diabetics 19 x more likely to have end

organ damage – therefore, absolute risk of chronic organ

impairment is:

The Intensive Care Unit I Alice Springs Hospital

Exploring Disease: Diabetes

Now explore the age group 20-45 years old:– 18 x more likely to have diabetes– indigenous diabetics 19 x more likely to have end organ

damage – therefore, absolute risk of chronic organ impairment is:

380

The Intensive Care Unit I Alice Springs Hospital

Why so much diabetes?

• 50,000 years

Desert MOB- thrifty gene

Foetal life:– poor nutrition during pregnancy

– gestational diabetes

The Intensive Care Unit I Alice Springs Hospital

Why so much diabetes?

50,000 years 150 years

The Intensive Care Unit I Alice Springs Hospital

Why is diabetes different?

The Intensive Care Unit I Alice Springs Hospital

Why is End-Organ Damage

Accelerated?

• High HbA1C is bad

• 50% of ASH indigenous diabetics

HbA1C >10%

• ? accelerators to endothelial

disease such as recurrent sepsis

The Intensive Care Unit I Alice Springs Hospital

Accelerators of endothelial damage

Two nations: racial disparities in bloodstream infections recorded at Alice Springs Hospital, central Australia, 2001-2005. Lloyd J Einsiedel and Richard J Woodman

Med J Aust 2010; 192 (10): 567-571

The admission-based BSI rate for Indigenous patients was 2.65% compared to 0.52% for non-Indigenous patients per year.

The Intensive Care Unit I Alice Springs Hospital

Alice Springs Hospital Data• Catchment area- 45,000 people; 15,000 are

indigenous, 10,000 indigenous adults

• 70-80% of the patients are indigenous

• 180 beds; 110-120% full

• 43,000 presentations per year to the emergency department– 10,000 over10 years with little change to

population size

• 28% readmission rate within 28 days

• 15-20% take your own leave rate

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

ASH ICU Outcomes

ASH Data Pooled ANZICS

Age: 50.1yr 60.9 yr

% indigenous: 65% 5.9%

APACHE II 19.7 15.6

% Emergency 95% 68%

ICU Mortality 2.15% 6.19%

The Intensive Care Unit I Alice Springs Hospital

Acute Pancreatitis

July 2003 to June 2010

• 1000 episodes of acute pancreatitis

• Annual Incidence : 259/100,000

• 206 in that group CT scan grade severe

– 96 of that group with necrosis

– 1 person palliated: 84 years old with an

advanced directive

• 205 in ICU - 205 survived

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

Is there a survival advantage?

• Genetic- mortality from sepsis is genetically linked

• Pre conditioning:Remote Ischemic Preconditioning: No Loss in Clinical Translation Michael Rahbek Schmidt, Steen Buus Kristiansen, and Hans Erik BøtkerCirculation Research. 2013;113:1278-1280

The Intensive Care Unit I Alice Springs Hospital

The Intensive Care Unit I Alice Springs Hospital

Road Deaths per 100,000 people

NT- 21.3

Australia-6.1

The Intensive Care Unit I Alice Springs Hospital