Benzodiazepines (diazepam or midazolam 20–240 mg/day either as a bolus or by i.v. infusion) were given to control muscle spasm and hypertonia. The indications for a surgical cuffed tracheostomy were acute airway obstruction due to laryngeal spasm, frequent spasms interfering with respiration or to facilitate mechanical ventilation. No patients were orally intubated and no form of subglottic suction or selective digestive tract decontamination find protocol was used. Arterial blood gases and peripheral oxygen saturations were

monitored regularly. In severe tetanus, the non-depolarizing neuromuscular blocking agent pipecuronium was used, using bolus doses titrated

against spasm. Autonomic instability was treated with increased sedation, morphine (20–60 mg/day intramuscularly), calcium antagonists, digoxin, volume expansion or inotropes (norepinephrine or dopamine) according to the clinical situation. Intermittent enteral nutrition was administered through a large bore nasogastric tube in those patients unable to swallow. An X-ray was used to determine correct placement of Cobimetinib supplier the tube before feeding commenced. Patients with a history of previous gastric ulceration continued to receive their regular medication, and those who developed Rebamipide gastrointestinal bleeding during the course of their admission were commenced on stress ulcer prophylaxis with either an H2 antagonist or sucralfate. Standard measures for general critical care and prevention of nosocomial pneumonia were employed and a pressure area care protocol was followed in

all patients. Closed suction was used for bronchial toilet. On average there were two patients for each nurse in the ICU. Admission clinical features, the presence of underlying disease, daily progress, the need for a tracheostomy and mechanical ventilation, duration and type of nasogastric intubation, type of stress ulcer prophylaxis, sedative treatment administered, intercurrent infections antimicrobial treatment given, the cost of antimicrobials given and the duration of ICU and hospital stay were collected prospectively on a dedicated study form. At the time of admission to the ICU, blood was taken for haematocrit, white cell count, platelet count and creatinine and a chest X-ray performed. The tetanus severity score (TSS) was determined for the time of admission with a cut-off point TSS ≥8 as predictive of death.