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Qatar Medical Journal - 2 - Qatar Critical Care Conference Proceedings, February 2020
2 - Qatar Critical Care Conference Proceedings, February 2020
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The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue – An important milestone
Authors: Ibrahim Fawzy Hassan and Guillaume AlinierEditorialDr. Ibrahim Fawzy Hassan
Local Host and QCCC 2019 Conference Chair
Dear Friends and Colleagues,
It is an honour to welcome everyone to the first Qatar Critical Care Conference (QCCC). It has been a long journey to make it happen, but this event has been much awaited by the local critical care community. Over the last few years, we have hosted a number of related events of various scales, ranging from Critical Care Grand Rounds targeting Hamad Medical Corporation (HMC) critical care clinicians, ran specialised courses, through to organising an international medical conference on extracorporeal life support in 2017.1 This inaugural QCCC event is the fruit of much planning and collaboration. The programme spans from 28th to 31st October 2019 and consists of two days of pre-conference workshops and two days for the main conference.
The vast majority of the pre-conference workshops will be held in the state-of-the-art ITQAN Clinical Simulation and Innovation Centre located within Hamad bin Khalifa Medical City. Although the facility is yet to be offically inaugurated and opened, we have the privilege to have been granted access to it as a way of showcasing our forthcoming continuing professional development capability. “Itqan” in Arabic means quality and striving for perfection, which is very much in line with the mission of our established Critical Care Network (CCNW).2 Simulation-based education is an area in which we have started to be very active through various immersive courses as well as innovative technological developments to train our extracorporeal membrane oxygenation (ECMO) specialists.3,4
The scientific part of the conference will be hosted in the iconic Sheraton Grand Doha Resort & Convention Hotel in the West Bay area. It includes a varied selection of topics presented by many renowned experts in their respective domain. This comprehensive programme with a line-up of lectures and workshops addressing e-CPR, ECMO simulation, ECMO cannulation, hemodynamics and so much more will facilitate the exchange of knowledge and experiences to improve patient care in Qatar and beyond. We anticipate that the programme will appeal to a broad audience and hence will bring together clinicians from all professions involved with caring for acutely ill patients. It is QCCC's aim to connect and explore new insights and expertise at a national and international level through networking with other professionals in a multidisciplinary setting. We hope that during this event many fruitful discussions will take place and that it will enhance opportunities for collaboration to develop everyone's practice in critical care.
The HMC Critical Care family has a capacity of 163 and 109 intensive care unit (UCI) beds, respectively for adult and paediatric patients, across 7 hospitals spread throughout Qatar. These numbers are complemented by another 52 adult and paediatric beds from non-HMC hospitals. This gives us a national ICU bed capacity of 11.8 per 100,000 inhabitants considering a current population of nearly 2,750,000 inhabitants.5 Although this number remains below the international benchmark which can be considered to be around 15/100,000 population,6 this quota in Qatar has more than quadrupled over the last ten years, which represents a very significant improvement in the care that can be provided to acutely ill patients. Within HMC only, it is supported by a workforce of 159 intensive care physicians, 1122 intensive care nurses, and many other clinical staff, all of whom undergo a well regulated programme of continuing professional development and are licensed to practise by the Qatar Council for Healthcare Practitioners (QCHP).7 The work they do across the various sites is coordinated and monitored by the CCNW2 who ensures the best level of care, up-to-date technology, and evidence-based practices are consistently adopted for the wellbeing of our patients.
Once again, on behalf of the Scientific and Organizing Committees, it is my pleasure to welcome you all to Doha and we hope that you enjoy and gain meaningful insights during the conference regarding our local critical care setting and practices, but also learn from the experiences and best practices shared by our international guest speakers.
Prof. Guillaume Alinier
Guest Managing Editor, Qatar Medical Journal QCCC Special Issue and Abstracts Chair of the QCCC Scientific Committee.
Dear Contributors and Conferences Delegates,
Welcome to this special issue of the Qatar Medical Journal (QMJ) which has been dedicated to the inaugural conference of the Hamad Medical Corporation (HMC) Qatar Critical Care Network (QCCN) which celebrates its fifth anniversary in 2019. I would like to start by thanking everyone who has supported this arduous publication endeavour through their extended abstract submission(s) and the reviewers for the valuable feedback they have provided to the authors to ensure this publication is a representative legacy of the calibre of this conference which includes many local and international experts in their respective field of practice or interest. All the accepted abstracts are being published Open Access thanks to the support of the conference sponsors and this contributes greatly to the sharing of experiences and best practices worldwide, but also showcases the good work that is being done in Qatar in the domain of critical care thanks to the work of dedicated clinicians and the leadership of the CCNW.2
Being the Guest Managing Editor of the special issue of a journal is an honour but also an arduous task, especially when a large number of submissions from international authors needs to be handled. It is the second time that I have accepted to take on that role for Qatar Medical Journal as the previous time was in 2017 on the occasion of hosting the South West Asia and African Chapter (SWAAC) of the Extracorporeal Life Support Organisation (ELSO) in Doha.1 This was only a couple of years after HMC had established its Extracorporeal Membrane Oxygenation (ECMO) programme, and it was a very successful event with many of its associated open access publications having been downloaded hundreds of times from the QScience.com publishing platform.
Working on this new Special Issue really made me reflect on how the domain of critical care is vast and encompasses so many aspects of patient care and so many professions and specialties. The topics of the abstracts published in this special issue of QMJ cover dietetics,8 sepsis,9 delirium,10,11 physical therapy,12 end of life care and organ donation,13,14 dealing with families,15 as well as education and training of clinicians,16,17 to only highlight a few. Critical care is fast moving as new clinical practices and technological innovations are adopted and contribute to continuously improving patient care. This is especially true in Qatar where significant investments are constantly made to develop and support healthcare in a strategic way.18 At HMC, the critical care phase that some patients have to go through so their medical needs can be met is well integrated across all stakeholder departments that can possibly be involved.2 The patient's journey through the healthcare system can be seen as a continuum of care facilitated by the fact that all parties involved belong to the same overarching organisation, HMC, which is the government funded main provider of secondary and tertiary healthcare in Qatar. This means that from initial contact with the Ambulance Service bringing a patient to the Emergency Department for example, right through to rehabilitation and even possible access upon discharge to a mobile healthcare service supported by family physicians, nurses, and paramedics, patients can expect the same high standards of care.19 Critical care provision relies on multidisciplinary communication during transition of care as well as during any acute episode. This needs to be underpinned by medical knowledge and understanding of the potential contributions of other professions as nothing can be left to chance when a patient's life is hanging by a thread. The present collection of editorials and abstracts brings different perspectives on a broad range of topics which should be highly relevant to all clinicians involved with critical care and contribute to improving patient outcome and satisfaction, and hence that of the multidisciplinary team members also involved in caring for them.
We hope that the Qatar Medical Journal Special Issue publications on critical care meets your needs and expectations. The complete record of QCCC publications including additional open access abstracts and editorials relating to this conference will be made available in Qatar Medical Journal at the following link: https://www.qscience.com/content/journals/qmj. Thanks again to everyone for your contributions, and beyond our email communications, I now hope to meet you in person during the conference!
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Critical Care Network in the State of Qatar
EditorialCritical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.1 The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.2 It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.3 Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand.
Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision – namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system.
The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.4 For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC.
As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.5
It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.6 This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients.
The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas:
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1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards.
2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required.
3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects.
4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers.
5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients.
6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment4 of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.7
The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various international accreditation awards by prestigious organisations and professional bodies.
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Surgical intensive care – current and future challenges?
Authors: Stefan Alfred Hubertus Rohrig, Marcus D. Lance and M. Faisal MalmstromEditorialBjorn Ibsen, an anesthetist who pioneered positive pressure ventilation as a treatment option during the Copenhagen polio epidemic of 1952, set up the first Intensive Care Unit (ICU) in Europe in 1953. He managed polio patients on positive pressure ventilation together with physicians and physiologists in a dedicated ward, where one nurse was assigned to each patient. In that sense Ibsen is more or less the father of intensive care medicine as a specialty and also an advocate of the one-to-one nursing ratio for critically ill patients.
Nowadays, the Surgical Intensive Care Unit (SICU) offers critical care treatment to unstable, severely, or potentially severely ill patients in the perioperative setting, who have life-threatening conditions and require comprehensive care, constant monitoring, and possible emergency interventions. Hence there is one very specific challenge in the surgical setting: the intensivist has to manage the patient flow starting from admission to the hospital through to the operating theater, in the SICU, and postoperatively for the discharge to the ward. In other words, the planning of the resources (most frequently availability of beds) has to be optimized to prevent cancellations of elective surgical procedures but also to facilitate other emergency admissions. SICU intensivists take the role of arbitrators between surgical demand and patient's interests. This means they supervise the safety, efficacy, and workability of the process with respect to all stakeholders. This notion was reported in 2007 when Stawicki and co-workers performed a small prospective study concluding that it appears safe if the dedicated intensivist takes over the role of the last arbitrator supported by a multidisciplinary team.1
However, demographic changes in many countries during the last few decades have given rise to populations which are more elderly and sicker than before. This impacts on the healthcare system in general but on the intensivist and the ICU team too. In addition, in a society with an increased life expectancy, the balance between treatable disease, outcome, and utilization of resources must be maintained. This fact gains even more importance as patients and their families claim “high end” treatment.
Such a demand is reflected looking at the developments that have taken place over the last 25 years. Mainly, the focus of intensive care medicine was on technical support or even replacement of failing organ systems such as the lungs, the heart, or the kidneys by veno-venous extracorporeal membrane oxygenation (VV-ECMO), veno-arterial ECMO (VA-ECMO), and continuous veno-venous hemofiltration (CVVH) respectively. This means “technical care” became a core capability and expectation of critical care medicine. In parallel, medical treatment became more standardized. For example, lung protective ventilation strategies, early enteral feeding, and daily sedation vacation are part of modern protocols. As a consequence, ventilator time has been reduced and patients therefore develop delirium less frequently. These measures, beside others, are implemented in care bundles to improve the quality of care of patients by the whole ICU team.
The importance of specialty trained teams was already pointed out 35 years ago when Li et al.,2 demonstrated in a study performed in a community hospital that the mortality was decreased if an ICU was managed 24/7 by an on-site physician. The association of improved outcomes and presence of a critical care trained physician (intensivist) has been shown in several studies since that time.3,, 4,, 5,, 6 A modern multidisciplinary critical care team consists at least of an intensivist, ICU nurse, pharmacist, respiratory therapist, physiotherapist, and the primary team physician. Based on clinical needs, the team can be supplemented by oncologists, cardiologists, or other specialties. Again, this approach is supported by research: a recent retrospective cohort study from the California Hospital Assessment and Reporting Taskforce (CHART) on 60,330 patients confirmed the association between improved patient outcome and such a multidisciplinary team.7
If such an intensive care team makes a difference, why do not all patients at risk receive advanced ICU-care? It was already demonstrated by Esteban et al., in a prospective study that patients with severe sepsis had a mortality rate of 26% when not admitted to an ICU in comparison to 11% when they were admitted to an ICU.8 Meanwhile, we know that early referral is particularly important, because for ischemic diseases the timing appears to make a difference in terms of full recovery.
So, the following questions arise: Should intensive care be rolled out to each ward and physical admission to an ICU or be restricted to special cases only? For this purpose, the so-called “Rapid Response Teams” (RRT) or “Medical Emergency Team” (MET), which essentially are a form of an ICU outreach team, were implemented. The name, composition, or exact role of such team varies from institution to institution and country to country. Alternatively, should all ward staff be educated to recognize sick patients earlier for a timely transfer to a dedicated area? This would mean that ICU-care would be introduced in the ward.
A first attempt to answer this question, whether to deploy critical care resources to deteriorating patients outside the ICU 24/7, was given by Churpek et al.9 The success of the rapid response teams could be related to decreased rates of cardiac arrest outside the ICU setting and in-hospital mortality. Interestingly, an analysis of the registry database of the RRT calls in this study showed that the lowest frequency of calls occurred between 1:00 AM to 6:59 AM time period. In contrast, the mortality was highest around 7 AM and lowest during noon hour. This indicates that not simply the availability of such a team makes a difference but also the alertness of the ward-teams is of high importance to identify deteriorating patients in a timely manner. Essentially, this would necessitate ward staff being trained to provide a higher level of care enabling them to better recognize when patients become sicker to avoid a delayed call to the ICU.
Alternatively, a system in which the intensivist plays a major role in daily ward rounds could be beneficial. So, the ward doctor should become an intensivist. However, the latter means the ICU is rolled out across the whole hospital which would consume a huge amount of resources.
Another option would be 24/7 remote monitoring of patients at risk that notifies the intensivist or RRT in case of need. The infrastructure, technology, and manpower to put this in place also has associated costs.
As the demand for ICU care will rise further in the future, intensivists will play an even more important role in the healthcare system that itself is under enormous economic pressure to ensure the best quality of care for critically ill patients. Besides excellent knowledge and hard skills, intensivists need to be team players, communicators, facilitators, and arbitrators to achieve the best results in collaboration with all involved in patient treatment.
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Sepsis Care Pathway 2019
By Ahmed LabibEditorialBackground: Sepsis, a medical emergency and life-threatening disorder, results from abnormal host response to infection that leads to acute organ dysfunction1. Sepsis is a major killer across all ages and countries and remains the most common cause of admission and death in the Intensive Care Unit (ICU)2. The true incidence remains elusive and estimates of the global burden of sepsis remain a wild guess. One study suggested over 19 million cases and 5 million sepsis-related deaths annually3. Addressing the challenge, the World Health Assembly of the World Health Organisation (WHO) passed a resolution on better prevention, diagnosis, and management of sepsis4. Current state of sepsis guidelines: Despite thousands of articles and hundreds of trials, sepsis remains a major killer. The cornerstones of sepsis care remain early recognition, adoption of a systematic evidence-based bundle of care, and timely escalation to higher level of care. The bundle approach has been advocated since 2004 but underwent major modifications in subsequent years with more emphasis on the time-critical nature of sepsis and need to restore physiological variables within one hour of recognition. A shift from a three and six-hour bundle to one-hour bundle has been recommended5. This single hour approach has been faced with an outcry and been challenged6–8. One size never fits all: Over several decades, the individual components of the sepsis bundle have not changed. Encountering a patient with suspected sepsis, one should measure lactate, obtain blood cultures, swiftly administer broad spectrum antimicrobials and fluids, and infuse vasopressors. A critical question arises: should we do this for all patients? Sepsis is not septic shock and guidelines did not make distinctive recommendations for each. Septic patients will present differently with some having more subtle signs and symptoms. Phenotypically, we do not know which patient with infection will develop a dysregulated host response and will succumb to sepsis and/or shock6–8. The existing bundle lacks high quality evidence to support its recommendations and a blanket implementation for all patients with ‘suspected’ sepsis could be harmful7. Indeed, a significant reduction of sepsis and septic shock in Australia and New Zealand was observed in a bundle-free region8. Emergency Department (ED) challenges: Upon arrival in the ED, patients will be triaged. This is ‘time zero’5. Those with hypotension and hypoperfusion will be easily recognised and at most need to receive emergent care. Sepsis, per se, may not manifest clear cut signs and expertise to identify it is required. Those with non-specific symptoms may trigger an early warning scoring system and receive unnecessary antimicrobials and a large volume of intravenous (IV) fluids. Both therapies are not without significant side effects. Putting pressure on ED physicians to implement the 60-minute bundle without individualisation of care puts our patients at risk6–8. Diagnostic challenges: Given the heterogenous nature and diverse pathobiological pathways, sepsis diagnosis can be challenging and both over and under-treatment can result. Established biomarkers such as procalcitonin and C-reactive protein lack specificity to rule out infection as the cause of inflammation. Currently, no laboratory test or biomarker helps predict which patients with infection or inflammation will develop organ dysfunction. A dire need for a specific sepsis biomarker exists10.
Modern molecular-based technologies are evolving and utilise polymerase chain reaction (PCR), nanotechnology, and microfluidics for point-of-care testing. Some devices identify causative microorganisms and their sensitivity in less than an hour10. The bundle components: Catecholamines along with IV fluids are indicated to restore perfusion. However, inadvertent side effects may arise, especially at higher doses. Anti-adrenergic ß-blockers improve cardiac performance, enhance receptor responsiveness, and possess anti-inflammatory action. All are desirable in patients with septic shock11.
One randomised trial showed beneficial and protective effects of ß-blockers in septic shock. Rapidly acting titratable agents should be used in conjunction with appropriate hemodynamic monitoring and after adequate volume resuscitation. There is no consensus on target heart rate but an arbitrary cut off of 80–95 beats per minute is reasonable11.
Fluid resuscitation is the cornerstone of sepsis management. There is also compelling evidence that too much fluid is bad. Starch-based colloids should not be used in septic shock. Albumin is an alternative when large volumes are required but is not appropriate in traumatic brain injury. Balanced, less chloride and less acidic crystalloids are safer for the kidneys and are preferred over normal saline. Doses of IV fluids should be tailored to the patient's condition and a 30 ml/kg recommendation should be reviewed.12
Effective sepsis management requires adequate dosing of antimicrobials. Significant alteration of pharmacokinetics and pharmacodynamics is characteristic of septic shock13. Accurate and effective dosing is challenging particularly in patients with multiple comorbidities and those receiving extracorporeal organ support. Underdosing results in treatment failure, whilst overdosing leads to toxicity and the risk of developing multi-drug resistant organisms13. An individualised approach supported by therapeutic drug monitoring is suggested to ensure clinical efficacy13. Sepsis research: The search for a cure for sepsis is ongoing. A large prospective, randomised two-arm, parallel group study aims to recruit over 200 patients with septic shock across critical care units in Qatar. Evaluation of Hydrocortisone, Vitamin C, and Thiamine (HYVITS) examines the safety and efficacy of this triple therapy14. Sepsis in the young patient: Children are particularly vulnerable to sepsis. 1 in 6 children admitted with septic shock to ICU will die. As the majority of paediatric sepsis cases are community acquired, there is a strong need to raise awareness both for families and primary healthcare providers. Akin to adults, a bundle-approach to paediatric sepsis is strongly encouraged. National programs for paediatric sepsis have been established15. The Qatar paediatric multidisciplinary sepsis program was established under the umbrella of the adult programme in 2017. A structured and standardised approach to sepsis across all neonate and paediatric facilities has been developed and implemented. Improvement in timely sepsis recognition and administration of antimicrobials within the golden hour has been observed. The program aims to achieve a 95% compliance to the paediatric sepsis bundle by the end of 2019. A screening tool and order set have been put in place and are presented in this special issue of Qatar Medical Journal16,17. Obstetric sepsis: Pregnancy and childbirth are risk factors for sepsis. Multi-organ failure and death can result from puerperal sepsis18. Sepsis is the direct and leading cause of maternal mortality in the UK19. Attention to maternal sepsis with a tailored approach is encouraged. The Qatar National Sepsis Program developed a sepsis care pathway for pregnant women and during their early post-partum period. Challenges in low socioeconomic societies: A broader, national –or better yet– a global approach to further sepsis management and outcome should be considered. There are a number of significant challenges to address. One such challenge is the inconsistency of the operational definition and diagnostic approaches for sepsis including coding and documentation1,3.
Significant deficiencies in healthcare systems have been highlighted by sepsis. This is most obvious in medium- and low-income countries. A major limitation to effective sepsis management is inadequate medical staffing and poor knowledge and awareness of sepsis. Both have a negative impact on sepsis outcome3.
Poor medical facilities in many countries pose significant challenges to sepsis care. Lack of critical care capacity – a global phenomenon – has been linked to poor outcome of sepsis cases and septic shock. This could be attributed to provision of suboptimal critical care, monitoring and critical interventions outside of the ICU. ICU availability is subject to inconsistency and inequity.2,3
Lack of adequate surgical capacity to accomplish timely source control adversely affects sepsis management. This, unfortunately, in medium- and low-income countries, is accompanied by inadequate medical supplies, diagnostic capacity, and manpower which increases sepsis mortality and morbidity3. Global concerns: Antimicrobials are critical for sepsis care. A global concern is the development of multi-drug resistant organisms and the lack of novel antimicrobials and this adds pressure on those caring for septic patients. Effective antimicrobials should be utilised to eradicate infections. Misuse, inadequacy, inferior agents, and lack of timely access to effective and affordable agents significantly hinders patient's recovery from sepsis2,3.
Optimum sepsis outcome mandates attention to acute sepsis complications (e.g. acute renal or respiratory failure) as well as addressing post-discharge complications and disability. These challenging issues remain poorly studied or addressed3. Conclusion: Sepsis and septic shock are major global health concerns. Progress has been achieved in understanding this life-threatening syndrome at a biological, metabolic, and cellular level. Efforts should be coordinated to improve sepsis care. Better and more accurate diagnostics are needed and governments are encouraged to invest in sepsis research and care. More integrated, inclusive, and focused research is desperately needed. Public education and increased awareness among primary healthcare providers are also critical to improve sepsis outcome.
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Trauma intensive care unit (TICU) at Hamad General Hospital
EditorialTrauma is a leading cause of mortality and morbidity worldwide, and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.1 In addition, approximately 100 million people are temporarily or permanently disabled every year.2 The situation is no different in Qatar, and injury related morbidity and mortality is increasing in the entire region, with road traffic collisions (RTCs) being the most common mechanism.1
It is well recognized now that trauma care provided in high-volume, dedicated, level-one trauma centers, improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness2. However, in general, it usually implies a high-volume of cases, dedicated full-time trauma qualified professionals, a solid pre-hospital system, a multidisciplinary team, and excellent rehabilitation services.
Similarly, critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU), has been shown to improve outcomes, especially for polytrauma patients with traumatic brain injury (TBI).3 In fact, the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU, and that a trauma surgeon be its director.4 Furthermore, studies have shown that for TBI, it is not necessary for this ICU to be a neurocritical care unit, but rather it should be a unit that is dedicated to trauma, that has standardized protocols for TBI management.5,6 In fact, the outcomes are better in the latter, with lower mortality in multiple-injured patients with TBI, when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).3 These benefits were shown to increase, with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.7
The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH), at Hamad Medical Corporation (HMC), including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry, as well as previous publications from our Trauma Center,1,8 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards, respectively.
With respect to HGH, the TICU is part of an integrated trauma program, the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH, striving to achieve the best outcomes, excellence in evidence-based patient care, up to date technology, and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit, emergency and trauma resuscitation unit, TICU, trauma step-down unit (TSDU), inpatient ward, and rehabilitation unit.
The new TICU is a closed 19-bed unit, that was inaugurated in 2016, is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants), along with 24 well-trained and experienced associate consultants or specialists, and fellows and residents in training, as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists, pharmacists, dieticians, physiotherapists, occupational therapists, social workers, case managers, and psychologists). It is supported by all medical and surgical subspecialty services.
It is equipped with the latest state-of-the-art technology and equipment, including ‘intelligent ventilators”, neuro-monitoring devices, ultrasound, point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM), and video airway devices.
The TICU is a teaching unit, linked to the HMC Medical Education department, with presence of fellows, and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU, as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon.
The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date, over 40 physicians from both within, and out of, the trauma department have completed the program. Up to seven fellows, including international candidates, are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery, anesthesia, and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020.
Residents (from general surgery, ER, ENT, plastics, orthopedics, and neurosurgery) rotate (one to three months’ rotations) in the TICU, and are actively part of the clinical team.
There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head, chest, abdominal, pelvic, spine, and orthopedic injuries, or isolated-TBI. Of these patients, 378 were severely injured with an injury severity score (ISS)9 greater than 16.
According to previously published data from our Trauma Centre,1,8 our mortality rates (overall approximately 6-7%, as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world, when looking at similarly sized retrospective studies.
The TICU continues to be an active member of the Critical Care Network of HMC.10 This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow, clinical practice guidelines, evaluation and procurement of technologies, HMC sepsis program, and in general, taking part in any process that pertains to critical care at HMC.
A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include:
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- Decreasing rates of infection in TICU
- Score-guided sedation orders to decrease sedation use, ventilator days and length of stay
- Reducing blood taking and associated costs
- Sepsis alert response and bundle compliance
- Medical and surgical management of rib fractures
Similarly, many research projects are taking place in the TICU, in coordination with the Trauma Research program, and often in collaboration with other departments (local and international). Examples of some of the research projects include:
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- The “POLAR” study (RCT on Hypothermia in TBI)11
- B-blockers in TBI (RCT-ongoing)
- Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing)
The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI,12 sepsis in TBI patients (ongoing), self-extubation in TBI patients,13 safety and efficacy of phenytoin in TBI (ongoing), and optic nerve diameter for predicting outcome in TBI (submitted).
The TICU at HGH is a high-volume, high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel, and utilizes the latest in technology and state-of-the-art equipment.
It performs very well, when compared to other similar units in the world, and achieves a comparable, or even lower mortality rate.
With continued great support from the hospital, corporation administration, and Ministry of Public Health, the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides, as well as perform a high quality and quantity of research, quality improvement initiatives, and educational work, in order for it to be amongst the best trauma critical care units in the world.
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Taking upstairs care outside
By Ian HowardEditorialBackground: Critical care is a clinically complex and resource intensive discipline, the world over. Consequently, the delivery of these services has been compounded by the need to sustain a specialized workforce, while maintaining consistent and high standards.1,2 The regionalization of critical care resources and the creation of referral networks has been one approach that has led to success in this area.2–7 However, as steps have been made towards regionalization, so too has the need to transfer patients between facilities in order to access these services. The effects of this are already apparent, where estimates in the United States have found that 1 in 20 patients requiring intensive and critical care resulted in transfer to another facility.2 The need for such transfers are equally varied as they are common and include: no critical care facilities at the referring facility; no staffed critical care bed availability at referring facility; requirements for expertise and/or specialists facilitates not available at referring site; and the repatriation of patients back to their original facility.6,8 An increase in the number of patients requiring the continuation of critical care in-transit has led to a need to expand the borders of traditional intensive care beyond the confines of the hospital. Such a concept fits with the assertions of Peter Safar, a pioneer of modern critical care, who proposed that critical care should not be defined by geographic location, but rather a set of principles designed to deliver appropriate and timely care to patients who need it.9Specialised transfer services: The advent and implementation of critical care transfer and retrieval services has been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Undertaking the transfer of a patient requiring the initiation or continuation of critical care is no simple task. Variations in patient type and severity of their medical condition, as well as the expectations of the transfer team are significant. Reports regarding the transfer of patients ranging from critical neonates, to the multi-comorbid geriatric; with complex underlying surgical and medical diagnoses; involving the concomitant administration of multiple vasoactive and sedative medications; with a variety of oxygenation and ventilation requirements, are commonplace in the literature.6,8,10–16 Consequently, moving these patients from the safety and security of one facility to another is an immense logistical challenge and fraught with risks. In addition to the severity of the patients underlying condition, limitations in space, personnel and equipment, as well an unpredictable operating environment are several of the potential hazards faced during the transfer of these patients.
These hazards are evident in the incidence of adverse events found in the literature. Incorrect referral triage; inadequate transfer team; patients requiring stabilization prior to transfer; equipment and/or technical failures; adverse drug events and medication errors are amongst the most common reported events.6,8,10–17
Further to this, the movement of patients alone has in itself been shown to have an impact on a patient's baseline status, without the occurrence of negative or untoward events.10,13,15,16 As a result, patient safety and quality of care have become essential components of modern critical care transfer and retrieval services, with the role of clinical audit central to their ability to learn and improve from previous cases and events. The local solution: Despite the relatively small size of the State of Qatar, critical care transfer and retrieval has nonetheless become a necessity within the country's healthcare system. Figure 1 highlights the locations of the main hospitals. Starting in 2014, a dedicated program was initiated to facilitate the transfer and retrieval of critical care patients across the country.18 The Specialized High Acuity Adult Retrieval Program (SHAARP) is a joint initiative between the Hamad Medical Corporation Ambulance Service (HMCAS) and the Hamad Medical Corporation (HMC) Critical Care Network (CCN). It consists of a single dedicated purpose-built ambulance, manned and run 24 hours a day, seven days a week by a variety of staff from both HMCAS and the CCN and deployed primarily for the transfer and retrieval of critical care patients across Qatar.19 The program was further developed in 2016 and formalized under the Transfer and Retrieval division of the HMCAS, with dedicated HMCAS and CCN staff receiving bespoke training and continued education;18 the addition of specialized and dedicated communications staff for call taking, dispatch and monitoring; and focused governance and audit to maintain the highest quality of patient safety and quality of care.
Since then, the program has seen considerable success and uptake within the country's health system. The activity of the unit echoes much of what can be found in the literature and further reinforces the need for such a specialized service, regardless of setting (Table 1). It further highlights the importance of the relationship and cooperation between the HMCAS and CCN regarding the expertise and resources that each component adds to the overall service. This is particularly evident in the expectations of the team regarding their duties of care whilst in transit. A significant proportion of the patients transferred by the program have required the maintenance of a high-level of care between facilities, under conditions that are far more challenging than that seen in any regular hospital ward or intensive care unit (Table 2). Conclusion: In modern healthcare, to deliver a consistent and high-level critical care service in any setting, the movement of patients is inevitable. However, in order to ensure the continuum of this level of care and maintain the highest standards of patient safety and quality of care in-transit, specialized transfer services are a necessity. The multidisciplinary nature of critical care transfer and retrieval dictates the cooperation between multiple in-hospital and out of hospital specialties and is a fundamental underlying concept in the success of such services.
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Rapid response team, is it still helpful?
Authors: Sayed Tarique Kazi and Emad MustafaFor the last three decades, efforts at improving the survival rate for patients post-cardiopulmonary arrest has remained unattainable. Confronting such challenge has opened the door to devise new strategies to improve patient outcomes at the onset of subtle deterioration, rather than at the point of cardiac arrest.1 In 2006, the Institute for Healthcare Improvement (IHI) introduced the Rapid Response Team (RRT) concept, also known as the Medical Emergency Team (MET), as one of the six preventative steps needed to save the lives of patients who might otherwise die unnecessarily.2 These six recommended interventions were included in a campaign by the IHI called the 100,000 Lives Campaign. A review of the literature was conducted to assess the certainty of clinical outcomes following the implementation of an RRT service within healthcare facilities. The main clinical outcome measures found included reduction of the:
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– Incidence of cardiac arrests that occurred outside the intensive care unit (ICU),
– Total ICU admissions,
– Unplanned ICU admissions, and
– Total hospital mortality rate per 1000 discharge.3
Despite the increasing utilization of RRTs worldwide, their effectiveness in reducing hospital mortality has been debated.4 However, the purpose of an RRT service is not to improve cardiac arrest management and outcomes. The primary focus of this concept is to identify patients before they deteriorate through improving patient monitoring on general wards (the afferent component) and improving the reliability of the response to deterioration by a dedicated Critical Care Outreach Team, Rapid Response Team, or Medical Emergency Team (the efferent component).4 The reliability of such systems depends on the faultless functioning of a “chain of survival” consisting of:
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– Timely recording of vital signs,
– Improved education and mindset of staff at the bedside to recognize pathological patterns,
– Reporting of abnormalities to the efferent team,
– Timely and appropriate response by the latter,
– Repeating feedback loops.
Metrics to estimate failure rescue rates have been developed and are widely used as indicators of hospital quality. The Agency for Healthcare Research and Quality has developed a measure of failure to rescue intended to address concerns about variation in documentation among reporting institutions and the fact that other metrics of patient safety, such as mortality and complication rates, may be more a measure of patient-related factors than quality of care. Those metrics are limited to some degree in their usefulness because some patients with advanced illness simply do not want life-prolonging interventions, and some adverse occurrences are not preventable. Nevertheless, recognition of failure to rescue as a significant issue and an important quality indicator has prompted numerous studies of the underlying causes and the development of systematic approaches to address them. It is time to stop asking whether RRT “works.” Overall, the balance of evidence indicates that RRTs are effective at reducing cardiorespiratory arrest and mortality. The focus should now be more on how to improve detection of patient deterioration and promote a culture of safety.5
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Biomarkers for sepsis – past, present and future
More LessSepsis is, in many patients, very difficult to recognise, especially early on and in the elderly and those with multiple comorbidities1. This difficulty leads to delayed treatment in some, and over-treatment in others in whom bacterial infection does not exist. One large study of 2579 patients admitted to critical care for presumed sepsis showed that 13% had a post-hoc infection likelihood of “none” and an additional 30% of only “possible”2. With increasing recognition of the many detrimental yet usually covert effects of antibiotics, such agents can only cause harm when given unnecessarily. There is a pressing need for reliable, early, sensitive, and specific biomarkers to (i) indicate the presence of infection, (ii) to indicate the likelihood that these infected patients will go on to develop organ dysfunction (sepsis), and (iii) to identify which specific treatments (e.g. immunomodulatory) should be administered to which patient in terms of timing, dosing, and duration.
Infection diagnostics have traditionally relied upon Gram stain and culture; the yield is low and often several days elapse before an organism is identified, speciated, and its antibiotic resistance pattern determined. Newer molecular diagnostics are arriving at an impressive pace and offer the opportunity for point-of-care testing at the bedside to identify micro-organisms (at least, the commonest pathogens), and some indication of antibiotic sensitivity, within minutes of sampling. Remarkably, bacteria within the lung can also be imaged in real time. As an example of the power of molecular diagnostics, one study involving 529 patients in nine European ICUs demonstrated that from 616 blood culture samples, polymerase chain reaction/electrospray ionization-mass spectrometry identified a pathogen in 228 cases (37%) whereas traditional blood cultures were positive in just 68 (11%)3.
For sepsis, current biomarkers such as C-reactive protein and procalcitonin are generally fairly sensitive but are too non-specific to accurately diagnose infection as the cause of inflammation, nor to identify which infected/inflamed patients will proceed to organ failure. Many patients will thus be unnecessarily treated with antibiotics while a smaller number may be inappropriately not treated. It is unlikely that a single biomarker will yield all the necessary information so technologies that can measure multiple markers will probably be more useful. Such devices are being developed, often for point-of-care testing, and include PCR (polymerase chain reaction), lateral flow, microfluidics, and nanotechnology4,5. These promise to deliver results in 30-75 minutes at the bedside with no need for involvement of the main hospital laboratory. The challenge now is to find the best biomarkers.
Finally, for treatment selection, it has become clear that sepsis is an umbrella syndrome with many patient subsets within. Inflammatory and hyperinflammatory phenotypes have been described from a combination of clinical and biological markers. At least from retrospective studies, it appears that these subsets respond differently to fluid, PEEP (positive end-expiratory pressure), oxygen, and corticosteroids. So targeted treatment may become a reality in the not-too-distant future though prospective validation is first needed.
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What matters in shock? Flow or pressure?
More LessShock is a state of ‘acute circulatory failure’, the key feature of which is an inability for tissues and cells to get enough oxygen to meet their needs, ultimately resulting in cell death1. Shock can be classified as hypovolemic, cardiogenic, obstructive or distributive although many patients will have several types of shock simultaneously1. Although it is important to identify and treat the underlying cause of shock (e.g., antibiotics and source removal for septic shock; thrombolysis or embolectomy for massive pulmonary embolism causing obstructive shock1, hemodynamic support must be started immediately in all cases to provide a minimum perfusion pressure and prevent development or worsening of organ dysfunction. In this context, both “flow” and “pressure” are important components. Indeed, the arterial pressure is determined by blood flow and vascular tone, i.e., blood pressure = cardiac output x systemic vascular resistance. The essential aspects of shock resuscitation can be remembered using the simple VIP mnemonic: ventilate (ensure adequate oxygenation), infuse (provide adequate fluid resuscitation), and pump (administer vasoactive agents). Fluid administration should be guided by repeated fluid challenges so that patients receive enough fluid but not too much, as excess fluid can have multiple harmful effects. If hypotension is severe, vasopressors should be started early, at the same time as fluids, to increase systemic vascular resistance and thus arterial pressure. Prolonged periods of hypotension are associated with worse outcomes2. Importantly, although an initial mean arterial pressure (MAP) target of 65 mmHg may be a useful aim, this will not be optimal for all and target values should be adapted according to the individual patient, taking into account various factors including age and history of chronic hypertension. Indeed, if the MAP target is too low, resultant hypoperfusion may lead to cellular death and organ dysfunction, but a target that is too high may be associated with edema and excessive vasoconstriction as a result of higher amounts of fluid and vasoactive agents3, which may also impair organ function. Patients with circulatory shock must therefore be carefully monitored, including regular assessment of cardiac output, and treatment and targets adapted accordingly. Monitoring organ perfusion at the bedside is difficult without specific tools to assess the microcirculation. As such, we must generally rely on three “windows” that can indicate inadequate perfusion, i.e., impaired cutaneous perfusion, impaired renal function, and impaired mental status1. Plasma lactate levels can also be useful, with changes over time providing some indication of adequacy of tissue oxygenation. Although these changes are too slow to help acutely guide therapy, the trend can provide valuable information about patient status over time. If flow remains inadequate and there is no, or only a poor, response to fluids, an inotropic agent may be considered. Dobutamine is the inotrope of choice. In this context, measurement of mixed (SvO2) or central venous (ScvO2) oxygen saturation can help as it provides an indication of the balance between oxygen delivery and consumption, with low values ( < 70%) suggesting that increasing oxygen delivery could be beneficial4.
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Performing cardiac investigations after VA ECMO implementation in adults
More LessVeno-arterial extracorporeal membrane oxygenation (VA ECMO) is commenced for adult patients with severe acute cardiac failure refractory to conventional therapy or following protracted cardiac arrest refractory to cardiopulmonary resuscitation.1 Following the commencement of ECMO there are several key questions which need to be addressed.
Initial investigations are those which are designed to understand the cause of the cardiac event, gain an understanding of the consequences of the event, particularly on other organ functions and also to direct initial treatment. At this stage, consideration should be given to basic biochemistry, electrocardiography, echocardiography, coronary angiography and computed tomography.2 These investigations can explain the origin of the cardiogenic shock and direct therapy, for example stenting of culprit lesions or management of an autoimmune cardiomyopathy.
Additionally, clinical monitoring tools should be implemented to allow understanding of the consequences of the cardiac insult and the impact of ECMO. One of the key problems of peripheral VA ECMO is the increase in afterload for the native heart which prevents appropriate left ventricular emptying.3 An early understanding of left ventricular end diastolic pressure as well as left ventricular emptying can assist in planning the need for left ventricular unloading devices. Investigations including direct measurements of left ventricular pressure at the time of the coronary angiogram can give a static measure of the impact of afterload. Continuous monitoring using pulmonary artery catheterisation with measurement of pulmonary capillary wedge pressure as well as intermittent echocardiography can help identify rises in left ventricular end diastolic pressure which may result in serious complications including pulmonary oedema, pulmonary haemorrhage, left ventricular distension and left ventricular thrombosis.
Investigations or clinical monitoring is also essential to facilitate optimal patient management. Early in the course of VA ECMO, there are naturally concerns about the ability of the ventricle to empty, however during cardiac recovery there is also the potential for the heart to eject deoxygenated blood, particularly if the lungs are yet to recover. Monitoring including continuous peripheral saturation monitors, arterial blood gases and cerebral near-infrared spectroscopy can all assist in understanding the relative provision of blood to the brain from ECMO or the native circulations.4 Similarly, continuous investigations of the blood supply distal to the cannulated peripheral artery are essential. There is a substantial risk of femoral arterial thrombosis and this can be managed through the use of intermittent doppler signals for the distal vessels or through the use of near-infrared spectroscopy for the legs.4
Finally, there is a requirement for monitoring and investigation of the pump and its function/impact on the patient. This includes identification of complications such as haemolysis, microthrombosis, air embolism and disseminated intravascular coagulopathy.5 Circuit gases can also be used to demonstrate functioning of the circuit and to prevent exposure of organs to profound hyperoxia or non-physiological pH.
In conclusion, there are a number of key investigations and clinical monitoring devices which should be undertaken following the commencement of VA ECMO to both understand the cause and to predict/prevent complications.
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Management of open complicated abdomen
More LessCritically-ill patients may have their abdomens opened as a result of primary pathology (damage-control laparotomy in trauma, soiled peritoneum from perforated hollow viscus, necrotizing pancreatitis), or as treatment for abdominal compartment syndrome (defined as new organ dysfunction associated with intra-abdominal hypertension).
The incidence and implications of intra-abdominal hypertension and abdominal compartment syndrome (ACS) in particular, are currently debated.
Intra-abdominal hypertension (IAH) is defined as a sustained intra-abdominal pressure ≥ 12 mmHg. Grading is possible; Grade I = IAP 12 to 15 mmHg, Grade II = IAP 16 to 20 mmHg, Grade III = IAP 21 to 25 mmHg, Grade IV = IAP >25 mmHg. Management principles include reduction of intra-abdominal gas (NGT and flatus) and intra-abdominal fluid (the latter may be interstitial or intra-peritoneal), and ensuring the abdominal wall is as compliant as possible. Definitive management is to open the abdomen however, the benefits and use of the open abdomen (OA) approach are unclear. The rates of OA appear to be reducing worldwide.
The reduction in the incidence of ACS requiring laparostomy may be related to global changes in resuscitation targets1, rather than changes in surgical techniques. In particular, the notion of ‘fluid de-resuscitation’ may be implicated in improved outcomes.
The decision to leave the abdomen open after emergent laparotomy seems to be dependent on the surgical specialty of the operating surgeon, and is a common approach applied in victims of blunt abdominal trauma2.
Complications of the open abdomen relate mainly to nutritional status and long-term abdominal complications. The most feared abdominal complication relates to the inability to close the abdominal fascia, with associated increases in mortality, fistula formation, and ventral hernias.
Current critical care focus is on the prevention of the open abdomen. For intra-abdominal hypertension and acute compartment syndrome, medical management aimed at reduction of abdominal wall pressure and evacuation of intra-abdominal contents (including fluid) are cornerstone strategies. The use of neuromuscular blocking agents is controversial; short-term benefit may be outweighed by long-term complications.
For the de novo open abdomen, current research suggests a possible role for more aggressive early closure (primary or before day 5, latest day 8). Further research is required to confirm whether primary closure is safe. Temporary closure techniques using a combination of negative abdominal wall pressure in combination with partial mesh reduction seems to be helpful in increasing successful abdominal closure rates3.
Aggressive infection control and nutritional support after 72 hours is key. Common to both scenarios is the need for careful, judicious fluid management; organ perfusion must be optimized, but not at the expense of massive bowel and abdominal wall edema. The latter complicates healing and closure4.
A final question is whether extubating patients with an open abdomen is safe and feasible. The literature provides a resounding yes to this issue5.
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Role of the intensivist for organ donation
More LessThe shortage of organs for transplantation is a serious medical problem. More than 90% of organ donors are patients who die after the irreversible cessation of all brain function in Intensive Care Units (ICUs) but 5–10% of these patients who fulfill the criteria of brain death suffer cardiac arrest before becoming an organ donor therefore their organs can no longer be utilized1.
Reasons why a potential donor does not become a utilized donor includes failure to identify/refer a potential donor, hemodynamic instability/unanticipated, and cardiac arrest with consecutive organ damage amongst others. Because the majority of potential organ donors are in the ICU, the critical care management guided by the intensivist plays a key role. The intensivist's responsibilities include the timely identification and referral of the potential organ donor for Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), optimization of the brain-dead donor by early goal-directed management of the physiological consequence of brain death, in addition to development and implementation of protocols and clinical pathways for DCD in collaboration with the organ transplant team in the hospital2. Identification and referral should be done as early as possible and should be guided by best available evidence guidelines e.g. the NICE Clinical Guidelines “Organ Donation for transplantation”. If not yet addressed, the organ donation team will approach the family to obtain their consent for organ donation.
The clinical picture of physiological changes that follow brain death is not uniform. Severity and occurrence of dysfunctions are related to the etiology and time course of brain death. Most common are hypotension, diabetes insipidus, hypothermia, and plasma electrolyte imbalance in comparison to pulmonary edema, metabolic acidosis, cardiac arrhythmias, and disseminated intravascular coagulation3. The general management principles in the ICU regarding DBD and DCD are similar. The donor management goals shall ensure physiological homeostasis to maintain the best possible organ function at the time of organ harvesting and includes cardiovascular, respiratory, fluid, electrolyte, hormone, blood, coagulation and temperature management to maintain normovolemia, hemodynamic stability, and normothermia4. A recent prospective study investigated the effect of the implementation of a Donor Management Goals (DMG) bundle that focused on maintaining parameters like blood pressure, central venous pressure, ejection fraction, arterial blood gas, PaO2/FiO2 ratio, sodium, blood glucose with support of low dose vasopressors within normal limits. The achievement of any 7 of 9 DMGs was associated with a substantial increase in the number of organs available for transplantation5. Meanwhile, many countries recognized that the principle of organ donation should be a routine component of end-of-life (EOL) care.
By implementing strategies of early identification and evidence-based goal-directed management protocols to preserve organ function, the critical care team guided by an experienced intensivist in collaboration with the organ donation team can help to improve organ availability and quality to overcome shortage of organs for transplantation.
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Prone positioning in ARDS: physiology, evidence and challenges
Authors: Husain Shabbir Ali and Megha KambleIntroduction: Prone position has been used since the 1970s as a rescue therapy to treat severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). Despite numerous observational and randomized controlled trials showing the effectiveness of prone position in improving oxygenation, mortality benefit was demonstrated only recently in the PROSEVA study1. Intensivists taking care of patients with ARDS should be aware about the physiological changes during prone ventilation, the latest evidence available and challenges that can be encountered in managing such patients. Physiology of prone position ventilation: When a person is supine, the weight of the ventral lungs, heart, and abdominal viscera increase dorsal pleural pressure. This compression reduces transpulmonary pressure in the dorsal lung regions. The increased mass of the edematous ARDS lung further increases the ventral-dorsal pleural pressure gradient and reduces regional ventilation of dependent dorsal regions. The ventral heart is estimated to contribute approximately an additional 3 to 5 cm of water pressure to the underlying lung tissue. In addition to the weight of the heart, intraabdominal pressure is preferentially transmitted through the diaphragm, further compressing dorsal regions. Although these factors tend to collapse dependent dorsal regions, the gravitational gradient in vascular pressures preferentially perfuses these regions, yielding a region of low ventilation and high perfusion, manifesting clinically as hypoxemia. Placing a person in the prone position reduces the pleural pressure gradient from nondependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity2 [Figure 1]. Clinical evidence: A few large randomized clinical trials, conducted over a period of 15 years, investigated the possible benefit of prone position on ARDS outcome [Table 1]. The improvements in oxygenation apparent in most trials were not associated with improvements in mortality, suggesting that oxygenation is not itself the source of improved survival with prone positioning. Most recently, the PROSEVA study group1 enrolled 466 subjects with moderate-to-severe ARDS. Mortality at 28 and 90 days was significantly lower with prone position versus supine position (16% vs 33%, respectively, p < 0.001, and 24% vs 41%, respectively, p < 0.001). Challenges: There are only a few absolute contraindications to prone positioning, such as unstable vertebral fractures and unmonitored or significantly increased intracranial pressure. Hemodynamic instability and cardiac rhythm disturbances are some of the relative contraindications. The common complications of prone positioning are pressure ulcers, ventilator-associated pneumonia and endotracheal tube obstruction. More serious fatal events such as accidental extubation is rare (zero to 2.4% prevalence). A recent meta-analysis of the safety and efficacy of the maneuver showed that it is safe and inexpensive but requires teamwork and skill. Reports in the literature suggest that the incidence of adverse events is significantly reduced in the presence of trained and experienced staff. Thus, centers with less experience may have difficulty managing complications, but nursing care protocols and guidelines can mitigate this risk4. Conclusion: Prone position ventilation in patients with moderate-to-severe ARDS improves hypoxemia, provides mortality benefit and is relatively safe.
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Diaphragm dysfunction: weaning perspective
By Nadir KharmaWeaning is the process of successfully liberating the patient from mechanical ventilation. The majority of patients will separate from the ventilator after a successful spontaneous breathing trial (SBT).1 In a minority of patients, weaning can be challenging and prolonged. Finding the cause of weaning difficulty is crucial to minimize the rates of extubation failure and prolonged ventilation.
Diaphragm dysfunction (DD) has been described as a separate entity responsible for weaning failure with an incidence of 23–80%. It has also been associated with difficult weaning, prolonged intensive care unit (ICU) stay and mechanical ventilation, and increased ICU and hospital mortality.2 Sepsis, shock, and ventilator induced diaphragm dysfunction are important risk factors of DD. Diaphragm dysfunction has several mechanisms. Disuse atrophy and microstructural changes of the diaphragm have been described as the two cardinal pathophysiologic features.
Establishing the diagnosis of DD can be complex in critically ill patients. Bilateral anterior magnetic phrenic stimulation is widely considered as the gold standard but is only available in large research centers with limited availability. Ultrasonography of the diaphragm is a promising tool given its wide availability, affordability, and non-invasive nature. Ultrasound is operator dependent, however and it does not provide continuous monitoring capabilities. The diaphragm thickening fraction (DTF) can be calculated from measuring the end-expiratory and end-inspiratory diaphragm thickness at the bedside. It correlates well with transdiaphragmatic pressure.3 Electromyography of the diaphragm may overcome the limitation of ultrasound by offering a continuous assessment of the diaphragmatic electrical activity, but it requires the placement of a specialized nasogastric tube.
Management of DD is better approached by implementing a preventive and a curative strategy. From animal studies, allowing for spontaneous breathing on mechanical ventilation may prevent the problem. The degree of the recommended patient effort and ventilator assistance to achieve optimal balance between diaphragmatic loading and unloading are yet to be defined. Monitoring DTF while finding the optimal ventilator support level can be useful in this context. Another modality to prevent DD is diaphragm pacing applied through a transvenous phrenic nerve pacing system. Animal studies in pigs showed that this modality resulted in less diaphragm atrophy when pacing was synchronized with ventilation.4 There is an ongoing study to assess the role of diaphragm pacing to recondition and strengthen the diaphragm in difficult to wean mechanically ventilated patients (Clinicaltrials.gov NCT03107949).
Once diaphragm dysfunction is established, no specific treatments exist at this time. Other causes of weaning failure like cardiac dysfunction have to be excluded and treated. Improving respiratory load and respiratory muscle weakness imbalance is also crucial. While it appears to improve inspiratory muscle strength parameters, inspiratory muscle training has not consistently shown improvements in weaning success.5 Levosemindan showed some benefit in improving diaphragm contractility and efficiency in healthy volunteers but was later found to increase likelihood of weaning failure in septic patients. Anabolic steroids were not found to be effective in treating diaphragm dysfunction in several studies. More evidence is needed before recommending non-invasive ventilation post-extubation in all DD patients.
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Intermediate pulmonary embolism: Diagnosis and management
More LessIntermediate (“submassive”) pulmonary embolism (PE) is proven acute PE without shock but with elevated troponin, BNP, or NT-proBNP, with either contrast-enhanced chest CT or echocardiographic evidence for right ventricular (RV) dysfunction, usually enlargement. However, definitions of intermediate PE vary widely: Some allow a single abnormality of any of the five (two imaging; three biomarker) results, and some would accept normal findings in all five but ECG evidence of RV strain. The quite varied criteria means recommendations for intermediate PE management frequently are not derived from the same type of patient. Diagnosis: Intermediate PE is considered after a diagnostic CT PA-gram with filling defects. The imaging study RV:LV cavity dimensions can be measured in the same image, but a ratio >1.0 is not predictive for adverse outcomes. Abnormal interventricular septum position and reflux of IV contrast into the IVC are associated with poorer outcomes. Echocardiography can measure RV and LV cavity dimensions in the 4-chamber view, but measurements without echo contrast are unreliable. Dynamic views of the RV can show impaired contraction, and/or reduced tricuspid annular plane systolic excursion (TAPSE), and/or elevated estimated pulmonary artery systolic pressure. But in a recent study by expert investigators, 27/83 (33%) of patients presenting to the Emergency Department with persistent dyspnea but CT PA-grams negative for PE had RV dysfunction by one or more of these echocardiogram criteria1. “RV dysfunction” is prevalent in dyspneic patients; in the acute PE patient, it may not be related to the PE. Thrombolysis: A randomized trial of weight-based IV tenecteplase vs placebo2 added to heparin compared outcomes in 500 patients in each group with intermediate PE, defined as requiring CT or echocardiographic RV dysfunction and elevated troponin. At day 30 tenecteplase deaths were 12 vs 16, respectively (p = 0.42) but significantly more strokes (12; 10 hemorrhagic, incidence 2.4%) vs 1 (incidence 0.2%) (p = 0.003), and extracranial bleeds occurred in 32 (6.3%) tenecteplase patients vs 6 (1.2%), (p < 0.001). Chronic thromboembolic pulmonary hypertension (CTEPH) was 2.6% in both groups after 3 years. An accompanying editorial3 concluded: No routine systemic thrombolysis; instead, observe for deterioration, for example, shock. To reduce bleeding, catheter-directed thrombolysis (CDT) for intermediate PE (mostly case series, sometimes ultrasound-enabled catheters; up to 20 mg rt-PA) has been reported. In the only randomized study (30 patients/group), ULTIMA4, 90-day mortality (0 vs 1), RV/LV ratio, and TAPSE were the same as with anticoagulation. 24-hour pulmonary artery pressure results were superior with CDT. Recommendations: In intermediate PE, observe carefully. Bolus IV heparin 80 U/kg actual body weight during the diagnostic work-up, infuse 18 U/kg actual body weight if the PE diagnosis is proven or likely. Obtain baseline BNP or NT-proBNP and follow every 6–12 h to help assessment. If hypotension occurs, consider half- or full-dose rt-PA5. If systemic thrombolysis is contraindicated, try catheter-directed thrombolysis by mechanical fragmentation or with 10–20 mg rt-PA infusion into the most important clot.
When active bleeding, impaired hemostasis, and high bleeding risk are concerns, give IV heparin without a bolus, 200–300 U/hour, and observe 6–8 h for hemostasis. Increase by 100 U every 8 h if tolerated without excessive bleeding until 600–800 U/h, then continue until bleeding risk remits. Consider a retrievable IVC filter.
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Do not attempt resuscitation (DNAR) conversation is not only ICU responsibility: experience as an emergency physician in Qatar
By Alhady YusofIn a busy and hectic critical care setting, sometimes an ‘emergency’ Do Not Attempt Resuscitation (DNAR) conversation has to take place to prevent unnecessary ‘futile care’. Traditionally, this is the responsibility of Intensive Care Unit (ICU) doctors after discussion with family members, or by the primary care doctors after discussion with patients themselves prior to them becoming critically ill. Many critically ill patients with known ‘terminal illnesses’ brought to the Emergency Department (ED) in Qatar do not have a DNAR order. Increasingly, DNAR conversation is being undertaken by Emergency Physicians (EP), alongside ICU doctors. Often, these difficult conversations with family members occur in the ED prior to escalating resuscitation, if time permits. In Qatar, three physicians need to sign the DNAR order if they think it is clinically appropriate. Patients or their family members do not need to sign. However, hospital regulation allows it only after discussion with and agreement from them. Often, the DNAR order also includes the maximum intervention agreed. Some family members object the DNAR order, and insist on ‘full resuscitation’ and organ support, despite explanation of the poor prognosis, and the likelihood of non-curable deterioration. This review looks at the current practice, challenges and evolution of ‘emergency’ DNAR conversation in critically ill adult patients in Qatar.
There are at least two different ‘opposing’ approaches to DNAR discussion with patients (and more often the case with family members of patients in critical care setting). The most often used is the patients’ choice approach1. In some society, patients discuss openly with their doctors about their condition fairly early on in the course of their illness. When they become critically ill, a similar discussion is undertaken with family members (or surrogates). A lot of emphasis is put on personal choices and preferences. Another approach, is a physician's driven DNAR recommendation when the clinical circumstance is appropriate2. This happens more commonly when patients present to hospital in late stages of their terminal illness (or with acute deterioration) without any DNAR order. In certain societies, DNAR is not generally discussed unless the condition is acute, life-threatening and the likelihood of a meaningful recovery becomes extremely small.
Both approaches are probably the two ends of the same spectrum (see Diagram 1). Both involve risk-benefit discussion (and likelihood of success with good outcome) of cardiopulmonary resuscitation (CPR) in the event of deterioration and cardiac arrest. Having agreed on a DNAR status does not mean that the patient will get substandard care. Patients and families have to be reassured of this fact. Given the appropriate care, many patients with DNAR status recover from their acute illness episodes and are successfully discharged home after emergency hospitalization3. An appropriate DNAR order will guide the medical team (doctors and nurses) to avoid unnecessary ‘futile care’, and hopefully lead to ‘better’ personalized care for patients and their families4.
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End of life – The nurses’ perspective
By Saumya BobyIntensive Care Unit (ICU) support is provided with the aim of maintaining the vital functions, reducing mortality and morbidity in patients with a severe critical illness.1 Despite having newly developed technologies and improvement in care, the death rate in the intensive care unit remains high, ranging between 20-35%.1 The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers.
End of life (EOL) in the ICU is a challenge. Nature and spirituality have been superseded by all that medical science has to offer by way of technology and life support, prolonging the dying process and dictating the time of death.2
Death as it occurs in the ICU is neither simple nor natural. Caring for dying patients and their families is thought to be most stressful and painful to the nurses who constantly attend to the patients whereas other healthcare providers can visit and then walk away.3 There are only limited studies from the perspective of critical care nurses on obstacles and/or supportive behaviors that either restrict or promote good care for dying patients even though there are adequate documentation of the difficulties and inadequacies of providing EOL care to patients.3
It is well identified that the nurses have a decision making role as they act as a link between families and physicians in decisions at the end of life while interpreting and explaining information.2
It has been noted that the nursing paradigm of enhancing communication, reducing symptom burden, and supporting families are aligned with the common domains of EOL care.4 The study using the grounded theory approach to formulate a conceptual framework of the nursing role in EOL decision making in an ICU setting concluded that the core concept, supporting the journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses describe being present with patients and families to validate feelings and give emotional support, nursing work, while bridging the journey between life and death, imparting strength and resilience and helping overcome barriers to ensure that patients receive holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.2 Thus involving the nurses in the multidisciplinary decision making of EOL care will be beneficial.
Nurses play a very important role in EOL care by providing family care and collaborating with the rest of the medical team.5 Working as a nurse within the wider ICU team requires good collaborative and communication skills and few studies have focused on how we foster these skills to enhance EOL care in the ICU. Little is known about the role of nurses in end of life in the critical care setting, and therefore a grounded theory study in this area is needed to further understand this important role.2
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Pediatric sepsis update
More LessPediatric sepsis comprises a spectrum of disorders that result from infection by bacteria, viruses, fungi, or parasites. Sepsis ranges from bacteremia, with early signs of circulatory compromise to complete collapse with multiple organ dysfunction and death. Early recognition improves outcomes for infants and children. Over the past two decades, sepsis has been defined and redefined with modifications for the pediatric population. The most recent iteration, complementing the NICE guideline (NG51) “Sepsis: Recognition, diagnosis and early management”, was published in 2017.1
Pediatric severe sepsis usually is community-acquired (57%) with the respiratory tract as the primary site of infection. Mortality rates associated with sepsis and septic shock in patients admitted to the pediatric intensive care unit are 5.6% and 17.0%, respectively.2
The SIRS adult criteria have been modified to produce pediatric-specific definitions. Per the 2017 Sepsis-3 guidelines, sepsis in adults is no longer based on the SIRS criteria, rather it is defined as an infection with at least one organ dysfunction. Although it may change in the future, the definition for the pediatric population remains based on the SIRS criteria due to weak evidence.3,4 Although not included in the definition of sepsis, hyperglycemia, altered mental status, and high lactate, are highly suggestive of sepsis and should be considered when evaluating a patient.
Risk factors for pediatric sepsis include less than one month of age, serious injury, chronic medical problems, immunosuppression, indwelling devices, and urinary tract abnormalities. Sepsis should be in the differential diagnosis in children with persistently abnormal vital signs such as tachycardia that is often missed and attributed to other causes. Hypotension is a late finding in children; the diagnosis of shock cannot be based solely on this finding. Unlike adults, previously healthy children can compensate extremely well during hypoperfusion states and do so for relatively long periods resulting in sudden decompensation.2
Timely response to sepsis is vital to survival. Vascular access needs to be obtained, fluids administered (minimum of 60 ml/kg), broad spectrum antibiotic coverage and initiation of inotropic support in fluid refractory shock need to occur within the first hour. Hydrocortisone should be considered with catecholamine-resistant shock and if at risk for absolute adrenal insufficiency. Laboratory diagnostics such as white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) are often nonspecific. More novel tests such as lactate and procacitonin are more specific clinical adjuncts that will support diagnosis, monitor, and trend a child's progress.1,5
Key recommendations of the 2017 guidelines highlighted the importance of bundles: “recognition bundle” with trigger tools for rapid identification; “resuscitation and stabilization bundle” to increase adherence with best practice principles; and a “performance bundle” to identify gaps and barriers in the system.1
Not every child with fever will have a serious infection leading to sepsis. Delays in recognition and management will worsen the prognosis significantly; early recognition is crucial. Any child with a suspected infection, persistently abnormal vital signs, or a concerning exam after antipyretics and intravenous fluids should be investigated and treated for sepsis. Rapidly changing standard of care makes sepsis a critical diagnosis for clinicians.
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Current Trends in Pediatric ARDS
Authors: Ikram U. Haque and Jai P. UdassiPediatric acute respiratory distress syndrome (PARDS) incidence is reported between 2.95 to 12.8 cases per 100,000 person years,1,2 which is lower than in adults but remains one of the most challenging form of lung diseases for a Pediatric Intensivist. Application of the adult ARDS definition is limited in pediatrics due to differences in risk factors, etiology, pathophysiology, hard to obtain PaO2 values, and lower levels and variation of PEEP utilization. To address these limitations, to promote early recognition and diagnosis of PARDS, and to improve prognostication and stratification of disease severity, the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first definition for PARDS in 2015.3
This definition (Table 1) kept the criteria of onset within seven days of a known clinical insult and the presence of respiratory failure not fully explained by cardiac failure or fluid overload. It eliminated the term acute lung injury, excluded bilateral infiltrate, and stratified severity of PARDS based on the oxygenation deficit as mild, moderate, and severe. Either oxygenation index or the oxygen saturation index (when arterial blood gas is not available) can be used to assess the degree of hypoxemia. Non-invasive ventilation is now included for continuous positive airway pressure of more than 5 cm H2O. Furthermore, PALICC included recommendations for defining PARDS in children with preexisting chronic lung disease, cyanotic congenital heart disease, and left ventricular dysfunction.
The PARDS management guidelines are based on very limited pediatric data and are largely based on expert opinions.3 For ventilatory management, no mode of ventilation is found to be superior, patient-specific tidal volumes per ideal body weight according to disease severity are recommended (3–6 mL/kg for patients with reduced and 5–8 mL/kg for patients with better-preserved compliance). In the absence of transpulmonary pressure measurements, plateau pressure should be limited to 28 cm H2O and 29–32 cm H2O during increased chest wall elastance. Moderately elevated PEEP to 10–15 cm H2O should be titrated in severe PARDS to the observed oxygenation and hemodynamic response. The oxygenation goal for mild PARDS (PEEP < 10) is 92–97% and severe PARDS (PEEP >10) 88–92%, although in some patients, < 88% can be considered with oxygen delivery monitoring. Permissive hypercapnia with a pH of >7.15 is the goal except in severe pulmonary hypertension, intracranial hypertension, select congenital heart lesions, significant ventricular dysfunction with hemodynamic instability, and pregnancy. Recruitment maneuvers by slow incremental and decremental PEEP steps may be used for severe hypoxemia. High-frequency oscillatory ventilation remains as an alternative ventilatory mode for patients with moderate-to-severe PARDS. There is not enough evidence to support the routine use of inhaled nitric oxide, steroids, or prone positioning for PARDS at this time.3
Since the publication of the new definition, several studies comparing the previous definitions to PALICC suggest that the PALICC definition can not only identify more patients with PARDS but it is also better at risk stratification for mortality.4,5 Despite decades of research and experience of managing PARDS, there remains a lack of definitive clinical evidence in Pediatrics. Further pediatric research is needed to gain more insight and to improve outcome of PARDS.
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Promoting NIV using ICEMAN methodology
Authors: Manu Sundaram, Ashwath Ram, Alberto Medina and Marti Pons-OdenaOne of the main reasons for children needing hospital admission is the need for respiratory support and monitoring. Intubation and ventilation has been the standard method of supporting patients in respiratory failure. With better ventilators and interfaces many of these children with respiratory failure could benefit from non-invasive ventilation (NIV). The main advantages of NIV over its invasive counterpart are reduced need for sedation, avoiding laryngeal and tracheal injuries, reducing nosocomial infections, and shorter length of stay.1,2
NIV can be used for acute conditions. Studies have shown that NIV is more successful in type 2 respiratory failure compared to type 1 respiratory failure as in type 2 respiratory failure, a failing pump is replaced by another pump i.e., NIV machine.3,4
With improvement in technology NIV has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. Use of NIV has not spread worldwide. Even in the countries where they are being used, there is huge variability in the use of NIV. This reluctance in usage could be partly explained by the lack of adequate scientific literature in children concerning this technology.
The first thing to do to overcome this barrier is to create an understanding and familiarity of this technology, resulting in more usage of NIV which has been shown to improve the quality of care and reduce cost of healthcare.
A FAST-NIVT (Forwarding Advanced Simulation Training in Noninvasive Ventilation Therapy) project supported by the Respiratory group of ESPNIC (European Society of Pediatric and Neonatal Intensive Care) has developed blended courses (online and face to face) for attendees and for NIV trainers in order to promote the teaching and learning of NIV around the world.
As an extension of this project we have developed a structured algorithm with the acronym ICEMAN (Figure 1) and used it to train our clinicians in the judicious selection of patients, contraindications and equipment used for NIV.2 This approach helps the teams to recognize failure of non-invasive ventilation, troubleshoot hypercapnia and hypoxemia, manage asynchrony and plan for weaning or escalation of care using algorithms.
We have conducted workshops globally to provide clinicians with best practice recommendations and guidance about how to best deliver non-invasive ventilation to patients who sometimes need this lifesaving technology. By attending this workshop, delegates would be able to understand the various indications, NIV options, modes of delivery, effective monitoring, and analysing failures which will definitely go a long way in providing this care more effectively with less failure.
All the workshops are led by trained educators who are experienced practicing paediatric intensivists, neonatologists, and pulmonologists with an extensive NIV experience. To make learning fun and to encourage participation, high-quality learning materials and skill stations have been tailored to the needs of each group. This methodology has been successfully used to train the next generation of clinical champions.
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Approach to circulation after cardiac surgery in children
Authors: Jai Udassi and Ikram HaquePediatric intensivists are called to patient bedsides in the pediatric cardiac intensive care unit (CICU) after congenital cardiac surgery for low blood pressure (BP) and/or poor perfusion, acute change in heart rate (HR) or rhythm, surgical site bleeding or increased chest tube output, anuria or oliguria, oxygen desaturation less than expected or metabolic acidosis with rising lactic acid and base deficit. Causes of acute circulatory failure after cardiac surgery are divided into four categories which must be considered when approaching the patient in CICU (Table 1).
Assessing cardiac output in CICU remains challenging, hemodynamic parameters are usually monitored, along with physical examination, i.e. HR, BP, right and left atrial pressures. There are surrogate markers i.e., mixed venous saturation, brain and renal NIRS, toe temperature, urine output, and then laboratory workup to determine acidosis due to end-organ dysfunction. Echocardiography can confirm low cardiac output syndrome (LCOS) occurs after cardiac surgery with the following major indicators; abnormal ventricular-vascular interaction after bypass, the functionally univentricular circulation, abnormal diastolic function after surgery to the right heart and residual anatomic lesions.1
The limited support tools that are available to manage circulatory failure post cardiac surgery in the CICU are the following: Medications: High labile pulmonary vascular tone (PVR) occurs in patients with pulmonary over-circulation i.e., ASD (atrial septal defect), VSD (ventricular septal defect), PDA (patent ductus arteriosus) and AV canal (atrioventricular canal). Pulmonary venous hypertension, i.e. TAPVR with obstruction, HLHS with restrictive atrial communication and in the univentricular heart after Norwood, shunt or PA band has unstable PVR. Functionally univentricular hearts don't tolerate increased SVR and at the same time, decreased SVR may not be desirable for patients who have fixed systemic or pulmonary obstruction. There are a wide variety of medications to use, but essentially two, milrinone2,3 and epinephrine are very important and widely used. Milrinone is routinely used after cardiac surgery to minimize the LCOS, which works in a receptor independent manner and is synergistic to beta-adrenergic ionotropic effect. Most patients benefit from low dose epinephrine for decreased cardiac function. Nitroprusside is effective where after-load is high, a low dose should always be started titrating to the optimal BP. Generally, there is no role of dopamine in these patients.4Ventilation-cardiopulmonary interaction: Ventilation at functional residual capacity needs to be targeted. Managing rhythm: Recognition of rhythm is a crucial aspect of care. It is equally important to pay attention to the appropriate heart rate. Extracorporeal mechanical support: The last resort is to put the patient on extracorporeal membrane oxygenation.
In summary, the past two decades have seen important advances in our understanding of the circulatory physiology of infants and children post cardiac surgery. When approaching the patients with cardiovascular dysfunction, it is essential to approach the cardiopulmonary system in its entirety, rather than consider the heart, lungs, or peripheral circulation as isolated elements. Working towards one common goal of optimizing systemic oxygen delivery and emphasizing anticipatory intensive care tailored to individual patients with the need for early, targeted investigation and intervention is essential when patients are not progressing as expected.
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Optimizing knowledge and skills through protocol-based ECMO management and simulation-based training: A novice clinician's perspectives of a successful ECMO program
Authors: Mohammed Elkhwad, Norita Gongora and Anna Vi GarciaBackground: Starting a new extracorporeal membrane oxygenation (ECMO) program requires synergizing different organizational aspects and extensive training of a core team to deliver care safely.1,2 Sidra Medicine, a newly opened facility in Qatar, started accepting acute inpatients and activated its ECMO program in 2018. The aim of this quality review is to evaluate the training of ECMO Specialists through benchmarking our ECMO program mechanical complications to the Extracorporeal Life Support Organization (ELSO) data. Methods: The hospital trained ECMO Specialists (experts and novices) come from different parts of the world with varying degrees of knowledge and experience and use a comprehensive training program based on the ELSO guidelines for ECMO training and continuous education.3 This program was delivered over a two-year period to all ECMO team members and included: multiple conferences on key ECMO topics; basic wet labs and emergency drills including the change of different components, and; immersive simulation-based training (SBT) on a modified neonatal manikin (Figures 1 and 2). These face to face interactions, in small groups, with different critical scenarios were followed by debriefing.4,5 SBT sessions started before the opening of the acute unit and continued after the acceptance of the first ECMO patient. Immersive SBT sessions occur monthly and include minor and major troubleshooting, de-airing, priming, circuit change, oxygen failure, pump failure, and other problems that can be encountered during ECMO runs.
All ECMO Specialists, both experts and novices, completed a full ECMO training program and had gone through the Sidra ECMO certification examination before handling ECMO patients. They were evaluated and certified using a checklist assessment tool and with skills having to be demonstrated competently by the candidates. Novice clinicians were initially ECMO bedside nurses and as they became familiar with the ECMO daily routine and learned the protocols and policies, they started caring for patients as ECMO Specialists.
We retrospectively reviewed collected data of technical complications for the 13 patients who have received ECMO therapy since program activation. We analyzed ECMO mechanical complications and benchmarked them with ELSO registry data in corresponding categories to evaluate the training of ECMO specialists and our ECMO program infrastructure. Result: The Sidra ECMO program has now trained a total of 20 ECMO Specialists (experts and novices). Out of the 13 novice clinicians who volunteered to be trained, 8 successfully became ECMO Specialists.
There has been a total of 13 patients on ECMO (Table 1). One of these was the first successful neonatal respiratory ECMO patient in Qatar. Over the 13 cases, minor mechanical complications and usual circuit clots were experienced. There was no pump failure or oxygenator failure encountered. Conclusion: SBT is a valuable ECMO educational approach. It offers the opportunity to practice technical skills repeatedly and to become proficient in high-risk/low frequency events while avoiding harm to patients. Using consistent and continuous training is the key for the success of the ECMO Specialist's model. This is a limited study due to the low number of patients, but as ECMO is a low-volume/high-risk procedure, it still highlights the benefits of simulation in establishing new ECMO programs.
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Advanced hemodynamic monitoring in critically ill neonates
By Samir GuptaThe neonatal circulation is unique due to the presence of fetal shunts. With the advances in biomedical technology, the assessment of sick newborn infants has improved significantly. It allows to collect, store and analyze the complex physiometric data and provides a foundation for advances in diagnosis and management of neonatal cardiovascular compromise. This could allow the clinician to have objective information to compliment the clinical assessment. Additionally, serial assessments and trending of measured parameters provides longitudinal information on disease pathophysiology and the response to treatment.
The advanced hemodynamic monitoring however has to be structured and focussed to get the relevant information to compliment clinical signs and symptoms. It however has an inherent risk of inappropriate or over-treatment leading to a state of confusion. The following questions should thus be addressed at the outset:
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1. Objectives of assessment and goal of therapy
2. Available techniques and processing information
3. Point assessment vs continuous assessment
4. Invasive monitoring vs non-invasive monitoring
When utilising these techniques, the limitations of individual devices and the interaction between them should be known. As compared to point-of-care assessment, when non-invasive monitoring devices are used, the trending of data from them with simultaneous single screen longitudinal display of values is helpful for diagnosis of disease and assessing response to treatment (Figure 1).2 The examples are continuous cardiac output, blood pressure, central venous pressure, pulse oximetry and near infrared spectroscopy. The trending of heart rate monitoring has already been utilised for early detection of sepsis using HeRO monitor. There has been interest in continuous amplitude integrated EEG but so far it is limited to research trials.
We compared measurement of cardiac output with echocardiography with non-invasive cardiac output monitoring. We observed that absolute values were different but the trend on longitudinal assessment was comparable. This could be due to the fact that non-invasive cardiac output assessment methods utilise indirect techniques such as electric velocimetry, arterial pulse contour analysis etc. Using an example of a baby with septic shock, one can understand how the hemodynamic monitoring can guide initial management.3
BP = cardiac output (CO) x systemic vascular resistance (SVR) (Figure 2) 4
If a patient has low CO, high SVR and normal BP, the choice of treatment is inodilators e.g., milrinone. If CO, SVR and BP are all low, commence treatment with norepinephrine and add epinephrine. If high CO and low BP and SVR, give fluid bolus initially and titrate therapy.
The integration of advanced hemodynamic monitoring in clinical care is akin to whole genome sequencing where a large amount of information is gathered which requires processing. Utilising this information is a challenge at present but it has the potential to open gateways for precision medicine.5
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Delirium in the PICU
By Tejas MehtaIntroduction: Delirium is a well-documented problem in the adult population however, its importance in the paediatric population has evolved recently with the development and validation of reliable paediatric delirium (PD) assessment tools. Definition: The key feature of delirium is an alteration in both cognition and arousal. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)1, defines delirium as a noticeable change in the patient's neurocognitive baseline with an acute disturbance in attention, awareness, and cognition, and is thought to be a direct result of another medical condition rather than due to an established/evolving neurocognitive disorder. Epidemiology: The overall prevalence of delirium in PICU ranges from 4% to 29%, with a recent multi-institutional PD study assessing 994 children for delirium in 25 different PICUs reporting a prevalence of 25%.2 Higher rates have been reported in children < 5 years of age.3 A PD prevalence of 49% was found in a paediatric cardiac ICU population. A prevalence rate of 27% was described in a postoperative paediatric population (delirium incidence of 65% within 5 days after surgery).3Pathophysiology: Many hypotheses have been proposed. The neuroinflammatory hypothesis suggests that systemic inflammation leads to endothelial activation, enhanced cytokine activity, and infiltration of leukocytes and cytokines into the central nervous system (CNS), producing local ischemia and neuronal apoptosis. The neurotransmitter hypothesis suggests that dysregulation of neurotransmitters like acetylcholine, dopamine, and gamma aminobutyric acid leads to the development of delirium. The oxidative stress hypothesis suggests that hypoxia coupled with increased cerebral metabolism, leads to the production of reactive oxygen species that cause global CNS dysfunction.3Risk factors: Risk factors are divided into predisposing and precipitating factors many of which are modifiable (Table 1).3Presentation: PD presents in three major subtypes. Hyperactive delirium is characterized by agitation, restlessness, hypervigilance, and combative behaviour, hypoactive delirium is characterized by lethargy, inattention, and decreased responsiveness and mixed type delirium which exhibits aspects of both hyperactive and hypoactive delirium.1 Hypoactive and mixed type delirium are common presentations in children followed by hyperactive variety. Hypoactive delirium can be easily missed without appropriate screening and diagnostic tools for assessment.3PD screening tools: Various screening tools have been developed to detect PD with their advantages and limitations (Table 2). Treatment: Management of delirium involves a multidisciplinary stepwise approach (Figure 1)3 including the management of the underlying medical illness, minimizing iatrogenic triggers, and optimizing the PICU environment. Pharmacotherapies are indicated if delirium persists and a child's agitated behaviour is distressful or interferes with medical care. Haloperidol, risperidone, and quetiapine have been used safely in children.5Outcome and prevention: PD is associated with increased length of mechanical ventilation, increased hospital stay, higher resource utilization, increased healthcare costs, and increased mortality. PD is a hospital acquired complication which can be prevented by using analgosedation approach with the goal to optimize pain and minimize sedation, minimizing iatrogenic factors, early mobilization, and involvement of family members in daily care.3Conclusion: PD is an important underrecognized issue in the PICU which needs to be prevented, detected early using screening tools, and managed using a multidisciplinary team approach.
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Concept of neuroprotective NICU
Authors: Mohammed Gaffari and Pranay JindalNeurodevelopmental outcomes are of paramount importance for every clinician as the survival rates of term and preterm babies have continued to improve. We aim to provide a framework for developing a Neuroprotective Neonatal Intensive Care Unit (NICU) by describing five main domains below. We achieve this in our NICU by a multidisciplinary team consisting of neonatologists, respiratory therapist, occupational therapist, physiotherapist, social worker, pharmacist, and a dietician. This approach needs to be individualised for each unit based on the resources and services available.
I. Neuro assessment: clinical neuro assessment remains the most important tool with strong predictive value for long-term outcomes. It is important to develop other tools of assessment like comfort and pain scoring. We use COMFORTneo scale as a standard of care.1 Neuroimaging is another important factor as part of the assessment. We have a local guideline to decide on the frequency and the timing of the neuroimaging such as cranial ultrasound and MRI.
II. Neuroprotection: antenatal magnesium sulphate and antenatal steroids have become an established treatment in most units.2 Interventions like total body cooling have significantly improved the outcomes for babies with hypoxic ischemic injury. One challenge faced in these babies is the ability to provide active cooling during transport when these babies are born outside cooling centres. Optimal nutrition is another important element for the developing brain. We developed neonatal nutritional guidelines in collaboration with the clinical pharmacist and a dietician. Introduction of starter parenteral nutrition bags for out of hours use in line with evidence-based feeding guidelines are known to improve the outcomes. We practice the golden hour protocol for all babies born before 28 weeks gestation and have introduced intraventricular haemorrhage (IVH) prevention bundles3 for the same cohort of babies. Even though individual components of these bundles do not have strong evidence, there is some benefit when these interventions are offered as a bundle. Our care bundle involves midline positioning, using log roll, minimal handling, maintaining normothermia, avoiding IV boluses, and maintaining normal CO2 levels etc.
III. Neuromonitoring: tools like amplitude-integrated electroencephalogram (aEEG), near-infrared spectroscopy (NIRS), and onsite MRI are gaining popularity. eEEG should be routinely used in hypoxic ischemic encephalopathy (HIE) babies when available. All team members should be trained in its application and interpretation. NIRS is a developing modality used by only a few units to monitor the cerebral oxygenation. We have recently started to pilot these machines.
IV. Neurodevelopment: the environment of the NICU has been shown to affect the developing brain. Strategies should be developed to optimise babies sleeping by reducing lighting and noise levels. We use positioning tools like boundaries and midliners as part of their neurodevelopment.
V. Neurointervention: we use therapeutic techniques like auditory, tactile, visual, and vestibular (ATVV) stimulation.4 It is an evidence-based technique used to increase alertness in medically stable preterm infants. We use Prechtl's Qualitative Assessment of General Movements observational tool.5 It is the most predictive tool (98% sensitivity) for detecting cerebral palsy. This helps provide targeted treatment at an earlier stage.
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The critically ill mother: Recognition and management (who, where and how?)
More LessThere is an ongoing debate about the management of the critically ill mother, notably with regards to who should manage this group of patients (the intensivist, the obstetric anaesthetist, or the obstetrician?) and where is the ideal place to manage them (labour ward, obstetric high dependency unit or the intensive care unit?). To make the most appropriate choice, an understanding of how to recognise maternal critical illness is paramount. Using the modified early obstetric warning system score (MEOWS) for obstetric patients is a useful tool 1. MEOWS looks at additional parameters to the standard early warning systems parameters with modified triggers to suit the altered physiology in the pregnant patient. Other predictors like APACHE and SOFA scores may also be used to predict maternal mortality 2. Data from several national audit and surveillance programs such as MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audits and Confidential Enquiries across the UK) 3, UKOSS (The UK Obstetric Surveillance System), and ICNARC (Intensive Care National Audit & Research Centre) are used to aid the understanding of why mothers die in childbirth and up to six weeks postpartum and which critically ill mothers are admitted to the intensive care unit and the reason for their admission 4. Audit reports show that a significant number of deaths reported in the maternal mortality reports are associated with suboptimal care. There is a great need for an evidence-based triage system for the critically ill obstetric patient in order to help clinicians direct them to the appropriate level of care and avoid situations of suboptimal care. Regionalizing maternal critical care may help develop this triage system by increasing the exposure to such patients. Deciding on who should manage these patients will depend on the level of training and expertise of the team members involved in the management on how to detect an acutely deteriorating mother. The team members should include obstetricians, anaesthetists, intensivists, intensive care nurses and midwives. The training can be achieved using different educational approaches that are competency-based to improve the knowledge and skills in detecting signs of deterioration in order to take the appropriate actions. Multidisciplinary teams should train together using simulation-based learning focusing on human factors and communication skills 5. Deciding on where these patients should be managed will depend on the level of organ support and monitoring available as well as the access to support services such as obstetric and neonatal services, regardless of what the terminology of that location is. The different models of delivering care to the critically ill obstetric patient with the different requirements for these areas are highlighted in Table 1. Taking all the previous factors into consideration will help find the answer to the WHO, WHERE and HOW question.
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Delirium in the ICU
Authors: Jo Ellen Wilson and Eugene Wesley ElyIntroduction: Delirium, the most prevalent form of acute brain dysfunction in the Intensive Care Unit (ICU) is characterized by inattention, changes in cognition and at times thought and perceptual disturbances (e.g., delusions and hallucinations). Recent estimates of delirium prevalence suggest around 70% of patients on mechanical ventilation will experience delirium during their critical illness and almost a third of days in the ICU are days spent with delirium1,2. There are at least three distinct motor subtypes of delirium: hypoactive (decreased movement), hyperactive (increased movement and at times agitation) and mixed (features of both). The hypoactive form predominates, is under-diagnosed and is associated with worse outcomes. Recent work has suggested that another psychomotor disturbance, catatonia may co-occur in up to a third of patients with delirium in the ICU3. Risk factors: Risk factors for the development of delirium include: pre-existing dementia, advanced age, hypertension, pre-critical illness emergency surgery or trauma, increased severity of illness, mechanical ventilation, metabolic acidosis, prior delirium or coma and use of certain delirium potentiating drugs such as anti-cholinergic and sedative hypnotic medications. Mechanisms: Exact mechanisms leading to the development of delirium are unknown, however early evidence suggests neural disconnectivity of the dorsolateral prefrontal cortex and the posterior cingulate cortex. Reversible reduction of functional connectivity of subcortical regions and neuroinflammation leading to hippocampal and extra-hippocampal dysfunction, may play potential roles. Overall all brain volume loss and disruption in white matter tracts may be associated with new onset dementia in survivors of critical illness. Due to the heterogeneous phenotype of delirium, there may be multiple causative neurobiological mechanisms contributing to its development, instead of one unifying pathway. Morbidity and mortality: Delirium is associated with significant morbidity and mortality. Much of the critical care literature about delirium has focused on the exposure of delirium and its relationship with acquired disabilities, as well as its effect on in-hospital and post-discharge excess mortality. Delirium is known to be predictive of new-onset dementia4, depression, excess mortality, longer lengths of stay, institutionalization at discharge, inability to return to work and increased cost of care in the hospital. Prevention and treatment: Despite scant evidence, antipsychotic medications have historically been the treatment of choice for delirium, however recent findings suggest that typical and atypical antipsychotics have no effect on delirium duration in the ICU5. As delirium is characterized by alterations in the sleep wake cycle, some studies have explored the role of melatonin or ramelton in the prevention or treatment of delirium, with early promising results. Non-pharmacological interventions such as complete adherence to the ABCDEF (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) bundle have shown benefit in reducing delirium prevalence in the ICU2.
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Multimodality monitoring in neurocritical care
More LessMonitoring the health of an injured brain is essential to forewarn neurological worsening and to gain insight into the pathophysiology of a complex disorder.
Clinical examination remains a cornerstone in monitoring patients with brain injury. The Glasgow coma score (GCS) is widely used but lacks information regarding brain stem functions like pupillary reaction and shows moderate inter-observer reliability. However, despite these shortcomings, GCS remains a robust indicator of the need for surgery and prognosis after cardiac arrest, hypoxic brain injury, and posterior circulation stroke. A new scoring system called Full Outline of Unresponsiveness has been proposed and shows excellent inter-observer reliability and includes points concerning brain stem functions.1
The most commonly used monitoring modality is intracranial pressure (ICP) monitoring. ICP shows threshold physiology where the outcome of the patients changes after a threshold of 20 to 25 mmHg. Refractory ICP is a good predictor of mortality but not of the functional outcome after traumatic brain injury.
Brain injury causes varying degrees of disruption to cerebral blood flow and its autoregulation. Studying autoregulation provides a useful strategy for targeting cerebral perfusion pressure close to the autoregulatory range. Transcranial Doppler and ICMplus (Intensive Care Monitoring) are used to study autoregulation. ICMplus is a software-based tool that studies the correlation between slow changes in mean arterial pressure and ICP to evaluate the state of autoregulation throughout the duration of ICP monitoring.2
Brain tissue oxygen measures the partial pressure of oxygen in the extracellular fluid of the neural tissue. Reduction in brain tissue oxygen is a marker of cellular distress. A phase 2 trial on brain tissue oxygen monitoring demonstrated the safety and feasibility of the protocol-based management of brain tissue oxygenation and ICP, and a trend towards lower mortality and improved functional outcome in patients treated with combined oxygen and ICP protocol.3
Microdialysis is a point of care test that monitors substrate delivery and metabolism at the cellular level. The lactate-pyruvate (LP) ratio is an indicator of the redox state of cells and a high LP ratio is associated with an unfavourable outcome.4
The electroencephalogram (EEG) is used in critical care for monitoring sedation and diagnosis of seizure activity. EEG is a complex signal which requires advanced training and skills for interpretation. Novel EEG-based monitors are aimed at simplifying the signal for straightforward interpretation by bedside medical professionals. Cerebral function monitor (CFM) is a compressed single channel amplitude integrated EEG monitor mainly used for the detection of status epilepticus and burst suppression during thiopentone infusion. A novel technique that uses direct electrodes applied on the cortical surface called Electrocorticogram (ECoG) shows spreading depolarisations on the cortical surface that are caused by loss of ionic homeostasis and substrate delivery.5 These depolarisations are a sensitive indicator of impending neuronal death and may serve as a target for novel mechanistically oriented therapies.
Detection, prevention, and monitoring of secondary cerebral insults that alter the prognosis from the injury, remains at the centre stage in neurocritical care. In the future, integrated informatics derived from multimodality monitoring will play a pivotal role in clinical decision algorithms.
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Adrenaline in cardiac arrest
Authors: Nicholas Raymond Castle, Ian Lucas Howard and Ian Ronald HowlandThe use of adrenaline during a cardiac arrest is well-established and supported by international guidelines. However, recent studies1–2 have questioned the appropriateness of adrenaline administration whereas other papers indicate that any benefit from adrenaline maybe time-sensitive.3–4
Two recently published studies have both challenged the use of adrenaline during resuscitation and whilst both papers used different methodologies they demonstrated similar results. The Paramedic 2 study1 was a placebo-based randomised control trial whereas the paper by Loomba et al.,2 used a meta-analysis of 14 peer-reviewed publications recruiting 655,853 patients, 7.4% of whom received adrenaline. Neither study was able to demonstrate any meaningful survival benefit associated with adrenaline administration (Table 1 and 2). However, both studies noted poor neurological outcome in post-cardiac survivors. It is noteworthy that both of these studies used different, but validated,5 neurological scoring systems (either the Modified Rankin Scale or the Cerebral Performance Category).
Whilst there is an acceptable correlation between the Modified Rankin Scale or the Cerebral Performance Category (Table 3) there is a degree of variation.5 This variation is partly due to what the two scales accept as being a good neurological outcome as well as an inbuilt degree of subjectiveness of any assessment of neurological status.5
Whilst The Paramedic 2 study1 and Loomba et al.,2 meta-analysis demonstrated no benefit of adrenaline, studies by Goto et al.,3 and Donnino et al., (adults)4 have published contradictory findings. Importantly Donnino et al.,4 reported improved neurological status in non-shockable cardiac arrest when adrenaline was administered.2 However, to date no study has demonstrated a benefit of adrenaline when used to treat shockable cardiac arrest.
Interestingly both Goto et al.,3 and Donnino et al.,4 indicated that any benefit from adrenaline administration was time-sensitive. Goto et al.,3 noted that the optimal time for adrenaline administration was < 9 minutes. Whereas, Donnino et al.,4 reported on the impact of increasing time delay to the first dose noting that when adrenaline was administered < 1 minute of confirmation of cardiac arrest, 12% of patients survived, but that this dropped to 9% after the fourth minute and was down to 7% after seven minutes (p < 0.001). The findings of Goto et al.,3 and Donnino et al.,4 represent a clinical challenge. Notably, during the Paramedic 2 study the average time of administration of adrenaline was approaching 20 minutes (6.6 minutes response time and 13.8 minutes) raising the question would the results of Paramedic 2 have been different if adrenaline was administered faster and whether adrenaline should only be administrated in witnessed cardiac arrest?
The routine use of adrenaline as the mainstay of resuscitation is being challenged, especially with regards to long-term patient survival and its role in the management of shockable cardiac arrest. However, in specific patients, when given early, adrenaline may still have a role to play in resuscitation. The 2020 International Resuscitation Guidelines are eagerly awaited.
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Prognostication in comatose survivors of cardiac arrest
More LessIntroduction: Hypoxic-ischemic encephalopathy (HIE) is the leading cause of death in comatose patients after cardiac arrest resuscitation.1 Poor neurological outcome is defined as death from neurological cause, persistent vegetative state, or severe neurological disability which is predicted in these patients by assessing the severity of HIE. Background: The most commonly used indicators of severe HIE include a bilateral absence of corneal and pupillary reflexes, bilateral absence of N2O waves of short-latency somatosensory evoked potentials, high blood concentrations of neuron-specific enolase, unfavorable patterns on electroencephalogram, and signs of diffuse HIE on computed tomography or magnetic resonance imaging of the brain.
Current guidelines recommend performing prognostication no earlier than 72 hours2 after return of spontaneous circulation in all comatose patients with an absent or extensor motor response to pain, after having excluded confounders such as residual sedation that may interfere with clinical examination. A multimodal approach combining multiple prognostication tests are recommended so that the risk of a false prediction can be minimized. Materials: Neuroprognostication is vital and yet continues to be one of the most controversial topics in post-resuscitation care. Specifically, concerning HIE, the 2006 practice parameters of the American Academy of Neurology provide specific recommendations for the prognostication of neurologic outcomes for cardiac arrest survivors not treated with therapeutic hypothermia (TH).
To date, there is no adequate paradigm for prognostication in HIE treated with TH.3 Clinical examination including the presence or absence of brainstem reflexes, motor responses and absence of myoclonus were traditionally used to predict a favorable prognosis. Electrophysiologic testing in the form of somatosensory evoked potentials (SSEP), the serum biomarker neuron-specific enolase (NSE), as well as neuroimaging, have been employed as additional tests to attempt to improve the predictive accuracy of neuroprognostication. However, what limited certainty these tests and parameters provided has become even more questionable in the setting of therapeutic hypothermia. The use of sedatives and analgesics adds a degree of uncertainty given unpredictable drug effects on patients’ neurologic status.
EEG, SSEP are the most common electrophysiological modalities utilized in neuroprognostication.4 EEG has been evaluated in the prognostication of cardiac arrest survivors and has also led to some essential clinical discoveries. The 2006 American Academy of Neurology (AAN) practice parameters assign EEG a false-positive rate (FPR) of 3% with a CI of 0.9; making it the least predictive method to determine neurologic outcomes. Abend et al., pooled four existing studies on EEG in cardiac arrest (CA) patients who had undergone therapeutic hypothermia and found that 29% of these patients had acute electrographic non-convulsive status epilepticus (NCSE).5Conclusion: There is no good evidence from well-designed studies to support substantial accuracy of early prognostication ( < 72 hours post-arrest) in cardiac arrest survivors treated with therapeutic hypothermia.2,6 Given our lack of understanding of how therapeutic hypothermia improves outcomes, as well as its effects on emergence from the coma and its well-described effects in altering drug metabolism and clearance, it is prudent to be more conservative in approaching prognostication. Patients should be observed for a minimum of 72 hours post-arrest. However, 5-7 or more days of observation may be necessary to fully account for the effects of therapeutic hypothermia.
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DVT prophylaxis in critical care: role of NOACS
More LessThe incidence of deep vein thrombosis (DVT) in the critically ill ranges from 3.6% to 37%. Despite seemingly adequate prophylaxis the risk for DVT is still between 4 and 15%.
Currently the known risk factors can be divided into inherited and acquired. In addition, the underlying disease and comorbidities play a major role, e.g., history of DVT, malignancy, ongoing infectious disease, cardiovascular disease and pregnancy1.
DVT prevention is applied in various ways and timings. Principally, the choice is between mechanical, pharmacological and a combination of both.
Regarding the mechanical prophylaxis, recommendations point more to the use of intermittent pneumatic stockings (IPS), which are more effective with less side effects than simple stockings2. Whenever pharmacological treatment carries a relatively high risk (e.g., fresh bleeding, traumatic brain injury) mechanical prevention might be started. However, it is still under debate whether the combination of IPS with pharmacological prophylaxis is superior.
Like all anticoagulant therapy, the risk (and consequences) of DVT should be balanced against the risk of bleeding. A variety of scoring systems, like the Well's score, the Caprini score and the Has-Bled score exist to group the risks. In terms of risk assessment, bleeding after peripheral surgery might be less dangerous than after intracranial surgery.
In general, low molecular weight heparins (LMWH) are preferred above unfractionated heparin (UFH). One reason might be the risk of heparin induced thrombocytopenia (HIT), which is higher with UFH than with LMWH. On the other hand, UFH have a shorter half-life necessitating at least two daily injections, while the LMWH schemes apply a once daily injection3. However, the shorter half-life and the ease of reversal might be an argument for UFH use in patients at bleeding risk. In contrast, LMWH's carry a higher risk of bioaccumulation4,5. The route of application seems to be another point of concern. In the critically ill, peripheral organ perfusion might be disturbed by the disease or the therapy (i.e. vasoconstriction or edema).
It is still a debate if oral anticoagulants should be used in critical care. Mainly concerns are raised from pharmacological considerations. For instance, if enteral feeding is only possible via tubes, grinding of tablets will change the galenic of the drugs and their bioavailability. In addition, it is not clear whether orally applied drugs will be resorbed completely. Excretion of drugs might be altered due to impairment of kidney and/or liver function which could result in their accumulation.
Finally, changes in the coagulation system due to the underlying disease might occur unexpectedly and therefore unanticipated.
In concert with difficulties in laboratory measurement and reversal of the drug benefits of oral anticoagulants do not outweigh risks and disadvantages. Therefore, it seems not recommendable to start any kind of oral anticoagulation before the patient's condition is stable enough which is mostly the moment of discharge from the ICU.
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Rheumatology in ICU
By Tasleem RazaAutoimmune rheumatological disorders are rare but important to consider in Intensive Care Unit (ICU) patients. Overall prevalence of these disorders is approximately 3% in the general population. About 25% of patients presenting with these disorders to the emergency room (ER) require hospital admission and up to one third require ICU admission.1 Mortality is variable and reported to be around 20% in recent studies.2,3
The most common rheumatological diseases requiring ICU admission are systemic lupus erythematous (SLE), antineutrophilic cytoplasmic antibody (ANCA)-associated vasculitides, rheumatoid arthritis, scleroderma, and dermatomyositis.1–3 The most common reasons for admission are infections and exacerbation of an underlying disease. The factors associated with mortality include Acute Physiology and Chronic Health Evaluation (APACHE) - II or Sequential Organ Failure Assessment (SOFA) score, vasopressors support, and prolonged hospital stay.2,3
In most patients with rheumatological disorders, the underlying disease is known at the time of admission. The diagnostic considerations in these patients include infections, underlying disease exacerbation, iatrogenic toxicity, or a rheumatologically unrelated disorder. The most difficult and challenging problem in these patients is differentiating between sepsis and exacerbation of an underlying disease, and laboratory markers may help in this differentiation. In SLE patients an ESR/CRP ratio >15 is suggestive of disease flare while < 2 is suggestive of infection. CD64, 2’5’-oligoadenylate synthetase (OAS) and soluble triggering receptor expressed on myeloid cell type 1 (sTREM1) are also promising biomarkers in differentiating infection and disease flare in SLE. A “bioscore” combining different biomarkers may be more useful than a single biomarker in differentiating disease flare versus infection.
Some medical conditions should always be on the radar of an ICU physician when patients present with multisystem disease with no clear underlying etiology. These include macrophage activation syndrome which may occur at any stage of rheumatic disease (onset, during active disease, during quiescent disease). A ferritin level of >10,000 microgram/L is pathognomonic, and >5,000 is highly suggestive of this diagnosis. Elevated aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), high CRP with low ESR may also help with this diagnosis.4,5 In scleroderma, renal crisis should never be missed and initiation of angiotensin converting enzyme inhibitors (ACEI) should be prompt to avoid morbidity. In any patient with livedo reticularis, digital ischemia, splinter hemorrhages, ulceration and superficial gangrene of lower limbs with multi-organ failure and SIRS, catastrophic antiphospholipid (APL) syndrome should be suspected. Any patient on methotrexate (MTX) should be evaluated for pneumonitis and bone marrow toxicity related to MTX. ANCA-associated vasculitis should be considered in any patient with combined respiratory and renal failure.4,5 Bronchoscopy should be prompt in this situation to rule out diffuse alveolar hemorrhage.
In summary, rheumatological disorders are relevant considerations in any patient with single or multi-organ failure in ICU when the underlying etiology is not obvious. A routine immunological screening may be lifesaving in this setting and prompts further work-up and diagnosis. It is extremely important to involve a rheumatologist early in the management of any patient with known or suspected rheumatological disorder. Frequent collaborative discussions and meetings may go a long way to improve prognosis of these patients in the short and long term.
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Pediatric sepsis improvement pathway: Qatar experience
Authors: Ahmed Labib and Rasha AshourBackground: The World Health Organization acknowledges sepsis as a global priority. Healthcare providers and governments have a critical role to play.1 National sepsis programs have been established in Qatar and in many other countries.1,2 Here, we share our pediatric sepsis program development and success. Missing signs of early sepsis in children can result in delayed management, complications, and death. A standardized pediatric sepsis pathway based on creating a “THINK SEPSIS” culture incorporating an electronic early warning system and improving effective communication among healthcare providers using standardized tools can help early sepsis recognition, timely management and proper escalation, and ultimately improve patient outcomes.3–5Methods: Building on the structure of the adult sepsis program, the pediatric sepsis committee was established in 2017 and a National Pediatric Sepsis Program was created.
It is based on a multifaceted approach of education, governance, awareness campaigns, and utilization of an electronic medical record system. Simulation sessions of pediatric sepsis were delivered to fill knowledge gaps. To further pediatric sepsis care in Qatar the following steps were completed:
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• Established a pediatric sepsis clinical pathway and guideline to be followed in all clinical areas at all times whenever a child is suspected or confirmed to have sepsis, hence avoiding variation of practice and saving valuable time.
• Introduced sepsis watchers in the daily safety huddle to facilitate continuity of care and alert staff concerning deteriorating patients.
• Provided a standardized pediatric sepsis diagnostic kit with all required investigation equipment and IV access to all concerned units to minimise delays and standardize care (Figure 1).
• Unified the pediatric sepsis antibiotics kits in all units with a safe first dose preparation protocol based on the most recent antibiogram to ensure the delivery of the first dose within 60 minutes of pathway activation.
• Rolled out an e-learning module which is simple, interactive, and evidence-based for staff to be acquainted with the program and to increase awareness.
• Developed an electronic pediatric sepsis order set allowing clinicians to initiate all elements of the sepsis bundle within a few minutes, saving time and ensuring consistency and reliability (Figure 1).
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1. The proportion of clinical review, Rapid Response Team activation, and sepsis alerts that were appropriately escalated is 91%. This is an important achievement to ensure timely intervention thus saving lives (Figure 2A).
2. 81% of patients received IV antibiotics within 60 minutes of time zero. This is an essential element of sepsis care bundle (Figure 2B).
3. Pediatric sepsis golden-hour order set was initiated in 26% of cases (Figure 2C).
4. Achieved sepsis bundle compliance of 42%.
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Optimal fluid management in sepsis
More LessSepsis clinically manifests as life-threatening organ dysfunction due to a dysregulated host response to infection.1 Optimal fluid resuscitation is relevant for all sepsis patients, and perhaps it is most important for those with septic shock. Septic shock is defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greatest risk of mortality, and septic shock is clinically identified as sepsis patients with serum lactate level >2 mmol/L and who require vasopressor infusion to maintain a mean arterial pressure ≥ 65 mm Hg in the absence of hypovolemia. Sepsis is among the most common conditions in the intensive care unit (ICU), accounting for up to half of all hospital deaths and being the third leading cause of death overall in the United States.2
Sepsis and septic shock are medical emergencies for which treatment and resuscitation should begin immediately. The goals of fluid resuscitation for these patients are: a) to rapidly replace intravascular volume and restore tissue perfusion, and b) to minimize organ dysfunction through timely interventions that either halt or reverse the physiologic derangements. If hypoperfusion is present, at least 30 mL/kg of IV crystalloid fluid should be given rapidly, and additional fluids should be guided by frequent reassessment of hemodynamic status, preferably using dynamic indices to indicate the likelihood of a beneficial response to fluid administration. Fluid administration should be targeted to achieve a MAP of at least 65 mm Hg, and to normalize lactate in patients with elevated lactate due to hypoperfusion.3
Balanced crystalloids are the fluid of first choice for sepsis resuscitation based on ready availability and taking medication costs into account. Use of 0.9% saline compared to a balanced crystalloid, such as lactated Ringer's or PlasmaLyte, produces more kidney dysfunction and with a greater risk of dying.4 The individual side effect profiles may best differentiate the natural and synthetic colloids. Albumin may be considered for administration to sepsis patients with refractory shock or who have received substantial amounts of crystalloid fluids, but should not be administered to patients with severe traumatic brain injury.5 Hydroxyethyl starch (HES) products should not be administered to patients with sepsis because of increased risk of acute kidney injury and death. Gelatin solutions are not recommended in sepsis.
Norepinephrine is the vasopressor of first choice for patients with septic shock, and should be administered to achieve a mean arterial pressure of at least 65 mm Hg after excluding hypovolemia as a cause for hypotension. The selection of a second line vasopressor, such as vasopressin, dopamine, phenylephrine, epinephrine or angiotensin-2, depends on patient factors such as underlying cardiac dysfunction, presence of arrhythmias, and current response to vasoconstrictor or inotropic agents. Dopamine should not be used for renal perfusion or protection and it should be avoided in patients with tachyarrhythmias.
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Pharmacokinetic/pharmacodynamic variations during sepsis/septic shock
By Dana BakdachSepsis, a heterogeneous syndrome, is usually associated with uncontrolled body response to a systemic infection leading to dysregulated pro- and anti-inflammatory cascades.1 This, subsequently, leads to immune suppression, tissue damage, and organ failure. With time, the natural body compensation is lost and a state of shock, characterized by profound hypotension and abnormal cellular metabolism, ensues. Sepsis and septic shock are thus considered major challenges in critical care management due to the high rates of complications, including morbidity and mortality. Successful management of sepsis/septic shock necessitates implementation of urgent treatment measures targeting the underlying infection, as well as improving patient's hemodynamics.2 Treatment measures include administration of antimicrobials, vasoactive drugs, sedatives, analgesics, along with others with the aim of achieving effective, yet safe concentrations of different administered medications at the targeted site of action.3 However, this aim of efficient medication dosing attainment can be challenging in critically ill septic patients. The host response to sepsis is usually associated with tremendous changes of different physiological processes.3,4 Different studies have shown that such pathophysiological alterations were linked to dysregulations in both pharmacokinetic (PK) and pharmacodynamic (PD) properties of different administered medications and thus result in complicated drug dosing.3,4
Pharmacokinetics of a given therapy is usually linked to the administered dose and the corresponded changes of concentrations inside the body with time, whereas pharmacodynamics describes the resultant relation between the obtained drug concentration and its pharmacological effect. In-vivo efficacy of an administered medication is largely driven by its intrinsic PK and PD properties. Variations in PK/PD are not always universal or easily predictable, and different aspects can affect the overall discrepancies. Those aspects include disease, patient and drug related factors.5 For instance, the alterations of PK/PD properties seen with sepsis can be different from those seen with septic shock. A similar thing applies to the drug properties where the therapeutic concentrations of a lipophilic medication might be less prone to changes as compared to a hydrophilic therapy. Likewise, the co-existence of different conditions that influence overall medications' pharmacokinetics can complicate proper prediction of therapeutic concentrations. This is frequently encountered in critically ill patients presenting with sepsis/septic shock and requiring the use of renal replacement therapy (RRT), extracorporeal membrane oxygenation (ECMO), plasmapheresis, or even all in certain individuals.
A deep understanding of various pathophysiologic changes seen in critically ill patients and their effects on the overall drug PK/PD is thus essential. This ensures that personalized dosing regimens are tailored to each patient to achieve an optimized therapy rather than using a “one size fits all” model of drug dosing. The implementation of personalized tailored therapy based on patient specific parameters, along with the utilization of therapeutic drug monitoring can successively give rise not only to improved clinical efficacy but also to decreased toxicity and antimicrobial resistance. Subsequently this would result in improved patient outcomes and survival.
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Beta-blockers in sepsis
More LessCatecholamines are an integral component of the host stress response and usually increase appropriately at times of need. Unfortunately, in severe and prolonged critical illness, they can contribute to significant harm with unwanted biological effects on cardiac function, inflammatory, immune, metabolic, and coagulation pathways1. A good example is Takotsubo (‘stress’) cardiomyopathy where heart failure ensues after an emotional stress resulting in extremely high levels of circulating catecholamines, considerably above that seen in a significant myocardial infarction2.
Unwittingly, we are likely contributing to catecholamine toxicity in our management of the critically ill septic patient through use of exogenous catecholamine therapies which carry the same detrimental effects as endogenous catecholamines1,3. Catecholamines are currently recommended first-line agents for septic shock, and are used in an attempt to overcome the vascular hyporeactivity and myocardial depression associated with sepsis. Use of higher doses of catecholamines is however associated with worse outcomes4. This is usually ascribed to the patient's underlying illness severity and an iatrogenic contribution is not considered – but perhaps should be.
Beta-blockers have multiple actions, on cardiac function and beyond. They reduce cardiac work through negative inotropic and chronotropic effects. Importantly, through slowing an excessive heart rate, both systolic and diastolic ventricular function are improved. They also act on adrenergic receptor responsiveness, enhancing the activity of catecholamines and allowing reductions in dose to achieve the same haemodynamic effect. Outside the heart, they improve vascular tone, enhance metabolic efficiency, and have anti-inflammatory effects and anti-thrombotic activity.
The first use of beta-blockade in sepsis goes back nearly 50 years with successful use in some patients in refractory shock. In the last decade an increasing number of observational studies and a few single-centre randomised controlled trials have shown both safety and improved outcomes5. These reflect findings in animal models of sepsis where various mechanisms were demonstrated including protective effects on the heart, anti-inflammatory actions and preservation of the gut barrier5.
Clearly, the patient needs to be adequately fluid-resuscitated and stabilised before commencing beta-blockers. Ideally, the use of a short-acting agent such as esmolol or landiolol allows easy titration, or cessation, of the infusion should hypotension or excess bradycardia occur with the unwanted effects wearing off within minutes. The largest study to date by Morelli et al., randomised 154 septic shock patients to receive either placebo or esmolol to reduce heart rate to 80-95 bpm. This was successfully achieved with no increase in complication rates compared to placebo. Importantly, there were also benefits in terms of earlier recovery of renal function, cessation of norepinephrine infusion, lower troponin levels (indicative of less cardiac damage), and improved survival rates. These encouraging findings need to be repeated in multicentre settings and two studies (one UK-based “STRESS-L”, one in 4 European countries) are currently ongoing.
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Debriefing in critical care
More LessDebriefing after critical events is a well-known practice in medicine, utilized in both simulated and real-life situations. In addition to reviewing the medical aspects of the care, debriefing allows for examination of team performance and human factors involved in the event. Various methods, locations, and time intervals can be utilized to debrief to meet the team's needs. Some proven methods of debriefing include plus-delta, directive feedback, the Socratic Method, and advocacy and inquiry.1 Each method has its benefits and limitations and can be applied during various segments of a debriefing to achieve the debriefer's goals. These goals usually include identifying and addressing knowledge gaps, uncovering participants' beliefs and thought processes, reflecting on the team's performance, and synthesizing the information to improve future performance.2 Debriefing should be a planned follow-up to every critical event. This standardizes the process and expectation for teams to share their experiences and work towards an improved performance. The debriefing environment should be a safe space for team members to express their emotions while sharing successes and challenges without fear of repercussion or blame. Allowing team members to share their decision-making process and knowledge level lets the debriefer tailor learning points to address appropriate deficits rather than assuming and targeting areas that may not need improvement. In addition, involving team members from all involved disciplines can enhance the outcomes of the debriefing. There is evidence that handoffs with more team members can improve efficiency, documentation, and future patient outcomes.3 The timing of these debriefs can be varied based on the clinical scenario and even the emotional state of the team members. Immediately debriefing after an event, also known as the “hot” debrief, allows most team members to participate and capitalizes on a clear memory of events to identify successes and opportunities for improvement. In addition to performance improvements, these sessions may help team members express their emotions and offer some coping skills to deal with unfortunate outcomes including the death of a patient. However, sometimes the debriefer may assess the emotional state of the team and deem it not appropriate to conduct the debriefing immediately after the event. In these settings a delayed debriefing session, or “warm” or “cold” debrief, may allow team members to process their emotions and reflect on the clinical event prior to coming together as a group to discuss their performance.
Despite the well described benefits of debriefing, there continues to remain a disconnect between knowing to conduct debriefs and their actual implementation. This can be due to various circumstances including, time pressures, patient care, or limited training in how to debrief a team. These failures to debrief can lead to communication breakdowns within the team.4 The absence of a debriefing can also lead to improper or inadequate documentation, which can result in clinical error and increased litigation.5 Organizations such as the Agency for Healthcare Research and Quality advocate for clinical event debriefing; this attention and effort on research and training can hopefully increase the frequency of and comfort with clinical event debriefing.
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Why don't we mobilize our ICU patients early?
More LessThere are several questions that need answering regarding mobilization of Intensive Care Unit (ICU) patients. How do we mobilize ICU patients? Is there an internationally agreed definition? Is there an internationally agreed prescription/program for mobilizing the patients? What is considered early? Why should we mobilize our patients, and lastly, why don't we?
Mobilization of ICU patients takes many different forms and views. It includes bed activities such as range of motion, turning, transferring, self-care, breathing exercises, sitting at the edge of the bed, and even stationary cycling. There are also several out of the bed activities such as sitting in a chair, standing, and walking. Although several units have their own protocols, a literature review reveals that definitions are either too broad or too narrow, subsequently challenging to transfer these results.1
Some trials have started mobilizing patients from as early as the first day, while other trials have waited 48 hrs, 5 days, and even longer before mobilization was started. Most trials which have managed to deliver very early mobilisation have found improved outcomes up to hospital discharge, while trials which intervened later mostly found no significant effect.2 The absence of a definition for early, very early, and late initiation of mobilization makes comparing studies very difficult.
Muscle weakness that develops during the ICU stay is called ICU-acquired weakness (ICU-AW). It manifests as generalized muscle weakness that is often severe. It develops in ICU patients who receive mechanical ventilation for 24 hours or more and is associated independently with prolongation of the duration of mechanical ventilation and ICU and hospital stay. ICU-AW is associated with increased mortality in the first year following ICU discharge. Mobilizing patients at an early time point decreases invasive mechanical ventilation (MV) duration, delirium, hospital length of stay, and reduced healthcare costs.3,4
Reported reasons for not mobilizing patients vary widely and include mechanical ventilation, catecholamine infusion, impaired consciousness, poor functional status, safety considerations, limited staff capacities, or lack of protocols. Absolute contraindications can include acute myocardial infarction, active bleeding, increased intracranial pressure with major instability, unstable pelvic fractures, therapy withdrawal, and lastly patients’ refusal.4
Recommendations on safety criteria for early mobilization mention that vasopressor use, endotracheal intubation, renal replacement therapy, or even life support devices like ECMO should not be considered as contraindications for active mobilization. Only one study has explored the safety of very early mobilization in critically ill patients on multiple support systems.4
Multiple QI projects have successfully implemented and sustained early mobilization projects within the ICU setting and all identified strong leadership for early mobilization. This along with the multidisciplinary team approach ensured success and sustainability of mobilizing ICU patients.5
In conclusion, there is a lack of internationally agreed protocols or guidelines on when and how we should mobilise our patients. There are also several obstacles facing us even once achieving consensus in that. The good thing is that we are clear on why we should mobilise our patients and hopefully this will drive further research to standardize the above unanswered questions.
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What is the future of ICUs?
More LessICUs in the future will comprise a larger percentage of hospital beds as care of less seriously ill patients shifts to home and other environments. ICUs will need to adapt to increased demand for services and concomitant economic pressures with efficiency and innovation. The future ICU will see changes in form, function, personnel and patients.
The type of patients in ICUs and their medical conditions will be different. Prevention, early detection, and timely treatment of conditions such as infection and respiratory failure should decrease the need for many ICU admissions. Patients needing ICU care will have multiple complex problems that shift the epidemiology of critical care. This shift in patient populations will not change the need for compassionate and empathetic care.
Precision medicine for patient care is the goal of the future ICU—tailoring therapy for conditions based on individual characteristics, risk profile or genetic markers1. Protocols and guidelines will require the ability to adapt to defined patient groups.
The physical ICU environment of the future must promote a healing environment for patients, families, visitors and ICU staff2. Optimal design should reduce noise, maximize work efficiency, minimize potential for errors, decrease infection risk, reduce stress and provide comfort for families and visitors. The environment will address sound, light, temperature, smell, art and entertainment needs. The ICU of the future must be a flexible environment with built-in adaptability for technological advances. Cohorting of critically ill patients in a defined ICU area will continue for efficiency but the flexibility to deliver critical care outside the physical ICU must also be provided. Patient-centered care will continue to drive services in the future.
The ICU of the future continues to require a highly trained collaborative team of professionals but roles and responsibilities as well as composition of the team will change. Intensivists will still oversee these teams but advanced practice providers and non-intensivist physicians may play greater roles in direct patient care. Greater emphasis will be placed on preventing burn out in team members through use of smart technology, optimum work environment and professional support.
Technology will be the most constantly changing variable in future ICUs that will affect the environment, patients, and staff. Sophisticated informatics will interface all hospital systems with the ICU and advance individualized care3. These systems must have characteristics of association, interoperability, integration, security, safety, and real-time synchronization4. Artificial intelligence and learning will address the challenges of information overload and integration of data to enable optimum decision making. Electronic “sniffers” will detect and interpret changes in patients’ clinical status and send alerts to clinicians or potentially initiate interventions. In addition, alarm systems will screen out irrelevant signals and decrease the danger of “alarm fatigue” but at the same time provide early alerts to safety issues and provide suggested actions. An outgrowth of advances in information technology will be the use of “big data” to optimize immediate patient care as well as advance research in the ICU5.
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Bridging the gap: Improving patient safety through targeted in-situ simulation training in a paediatric intensive care unit and Learning from Excellence (LfE)
Authors: Prabhakar Nayak, Nikki Kidd, Bianca Osborne-Ricketts, Jeff Martin, Yvonne Heward and Adrian PlunkettBackground: Improving patient safety and reducing risk is important to a Paediatric Intensive Care Unit (PICU). Simulation-based education has generally focused on the management of clinical diagnoses, whereas the Quality and Safety Team has traditionally focused on collecting and analysing data about adverse events. There is a need to bridge the gap between the two streams - lessons learnt from adverse incidents and their impartation to staff in a targeted format during in-situ simulation training.
Methods: Birmingham Children's Hospital PICU is a 31-bedded tertiary/quaternary unit with approximately 1500 admissions per year in the UK. All adverse incidents are collated (online IR1 with specific forms for incidents involving medications, accidental extubations, buzzer pulls, and extravasations) and analysed by the PICU Safety Group and trends are monitored. The PICU Simulation Team delivers in-situ simulation training for the multidisciplinary PICU staff weekly using interactive, computer-controlled manikins. Each training scenario and debriefing lasts 1 hour. A core team of multidisciplinary simulation facilitators runs the simulation training and the AI (advocacy-inquiry) debriefing model1 is used for conducting the debriefings. The ‘Simulation Group’ (efferent) and the ‘Risk Group’ (afferent) regularly discuss the priorities for the unit and the lessons learnt based on actual events or near-misses in the unit. It then implements the action points during targeted scenario training sessions. This may be the utilisation of a care bundle or activation of a ‘clinical pathway’. Any practical problem with implementation of these policies is fed back to the Risk Group to close the loop. A concept of ‘Learning from Excellence’ (LfE) has been introduced successfully and both ‘adverse incidents’ and LfE are used together as approaches to improve patient safety in the unit.
Observation/Evaluation: Various simulation scenarios have been run since the start of the project. Examples include accidental extubations, delay in sepsis recognition and antibiotics prescription, ischaemic limb injury due to the indwelling arterial line, emergency chest reopening in post-operative cardiac surgical patients, child protection and safeguarding2. The learning gained during each debriefing is generalised to all the participants of the simulation session3 and then subsequently the salient points are shared by email with the entire unit. All staff members have to undergo simulation training. Scenarios are re-run back to back if the team does not achieve the expected outcomes. The anonymous feedback forms completed by the participants of the scenarios have shown they value this targeted training and that it has helped them implement good practice. Anecdotaly, the trend of ‘incident severity’ is believed to have been on the decline over a 7-year period in our PICU but long term monitoring will continue to identify any re-emerging or fresh trends.
Conclusion: ‘Targeted’ simulation-based training is an important approach to enhance the safety culture in PICU. PICU Safety and Simulation Groups should develop a symbiotic relationship for this to succeed. Learning from Excellence can be effectively utilised to embed good practice in a clinical area.
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Social media and critical care
By Mamoon YusafSocial media has transformed the way we communicate with each other in the last decade or so. Out of 4 billion internet users, more than 3 billion are on social media. The medical community has also been transformed in terms of how we approach this vast medium of information. Microblogging sites like Twitter are beneficial in the way we share and disseminate professional knowledge. The critical care community has recently gained a lot of pace on the social media platform and are showing their presence in numbers.1 Although use of social media in critical care has great potential to benefit its users, it comes with its own challenges. This includes inaccurate information and slow adaptation. So the question arises: How can the critical care community make the best use of social media resources while ensuring the right knowledge is shared and practiced, and patient confidentiality is always respected?
Twitter has been used as a medium to not only spread information but also as a platform to teach critical care physicians and nurses. There are elements which affect the usability, efficiency, effectiveness, and widespread acceptance of Twitter as a teaching aid.2 FOAM, free open access medical education, is an online movement taking place across social media, blogs, and podcasts that is challenging traditional methods of medical education.3 FOAM provides a free platform for learners to not only receive information but also share it with other users. It gives the learner a chance to tailor their resources according to their individual needs. In addition, learners can reach out for assistance from the source much more easily as compared to traditional ways. But concern has been raised on how to best approach these resources as they do not undergo vigorous checks like peer reviewed articles. Check and balance of the validity of the provided information is often left up to the learners discretion. It can leave educational gaps at times and may not be applicable worldwide. Similarly, declaration of conflict of interest is not mandatory on these platforms hence it is often impossible to identify commercial bias.
It can be quite difficult to keep track of all the continuing professional development hours spent on social media but new applications are being developed, which can help. While on social media, all the norms and etiquette of healthcare professionalism should be maintained such as patient confidentiality and appropriate interprofessional relationships. There are evolving tools to evaluate the quality of various resources like SMi (Social Media Index)4 and HONcode (Health on the Net Code of Conduct).5
Social media, when used correctly, can be effective for self-directed learning, holding discussions with other critical care and healthcare professionals while reflecting on newly-acquired knowledge. Although the information must be used with due care, as the peer review is mostly inexistent in social media as people can post what they want, it is one of the most exciting and evolving areas in critical care practice.
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How to do clinical trials in the ICU
More LessSite-initiated clinical trials are challenging, particularly with vulnerable populations like ICU patients. But they can be useful if you can answer “Yes” to these questions: (1) Could the answer change practice? (2) Does my ICU see enough of these patients to answer the question? (3) Can I treat both the investigational and control group patients in a fair manner? Other approaches to ICU clinical research, such as joining another multicenter clinical trial and observational (prospective or retrospective) studies whose answers have explanatory power may also be valuable.
Regarding changing practice: The trial's answer should be important enough that any intensivist treating such a patient would care about it. Examples of questions that probably aren't important enough are: (1) Is there a difference in ARDS outcome if the tidal volume is 4, 6, or 8 mL/kg?, (2) Is knee-high pneumatic compression inferior to thigh-high pneumatic compression for thromboembolism prophylaxis in anticoagulant-contraindicated patients?, and (3) Do piperacillin-tazobactam and cefepime have equivalent efficacy for empiric coverage of hospital-acquired infections? The first question probably has a patient-specific, non-generalizable answer; the second, with small “dose” differences has high risk of being a negative study; the third answer likely depends on local organisms, and equivalence studies require very large patient numbers.
Studies whose answers probably could change practice include: (1) Does adding Extracorporeal CO2 Removal (ECCO2R) to intubated ventilation in combined respiratory and metabolic acidosis improve survival/shorten ventilator time?, and (2) Does extracorporeal CPR (ECPR) for witnessed out-of-hospital cardiac arrest with a shockable rhythm save lives? Regarding the ECCO2R proposal, current practice involves hyperventilating high-dead-space patients, pressors, bicarbonate infusion, maybe dialysis, and outcomes are poor. ECCO2R can reduce ventilatory and alkalinizing/dialysis requirements1. Regarding the ECPR proposal, current survival rates reported after 60 min of CPR without ECPR for possibly salvageable patients are 9%; with ECPR, 22%. Moreover, there are no clinical trials published2.
The second criterion is important because if your site doesn't see enough patients, coordination with multiple centers and delay can imperil completion. Estimating sample size early for feasibility is important. For the ECCO2R proposal, an estimate for 30-day survival of such patients is 25%. To double survival to 50%, 2-sided p = 0.05, with 80% power, sample size is 65/group, 130 patients altogether. For the ECPR proposal, an estimate without ECPR is 5% survival after an hour of CPR. To raise survival to 25%, 2-sided p = 0.05, with 80% power, sample size is 58/group, 116 patients. These numbers may be practically achieved in some centers after 2-3 years, when the answers will still be pertinent.
The third criterion addresses whether the question is practical: Can a protocol fair to patients be devised and executed? For both ECCO2R and ECPR proposals, the protocols must (1) Establish criteria to assure no prolongation of life just to favor one unblinded group or another, and (2) Establish a process to assure uniform patient entrance and procedures among participating physicians and centers. Careful thought and collegial consultation at the start of study planning is important for helping ICU patients with your clinical research. Preparing the final study report similarly requires close attention and consultation3.
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Burnout signals are alarming worldwide: the active role of leadership
Authors: Amr S Omar, Yasser Shouman and Suraj SudarsananIntroduction: The burnout phenomenon first came to clinical science 50 years ago. It is exponentially rising worldwide which prompted its discoverers to develop the most popular tool for its assessment, known as the Maslach burnout inventory (MBI)1. Common symptoms of burnout include depression, irritability, and insomnia. It is known to hit professional areas where higher levels of stress are common. Intensive care unit (ICU) practitioners are particularly vulnerable to this condition. Bienvenu reported that up to 45% of ICU staff experienced burnout at a certain time in their career. The contributing factors include: age, gender, work schedule, involvement in decisions of withdrawing life support, policy of visiting hours, work quality, and care of dying patients. It is described as a growing crisis and is currently gaining a lot of interest aimed at addressing the issue and its consequences2. We hypothesize that positive leadership with empowerment of staff may have an impact on burnout. Our objectives are to explore the prevalence of burnout in this area, to find the contributing factors, and determine the impact of the role of empowerment and leadership on burnout. Method: We conducted a cross-sectional descriptive study using a combined methodological quantitative and qualitative approach involving a convenience sample of 200 healthcare practitioners within surgical and medical ICUs of Hamad Medical Corporation (HMC), Qatar. We used two main instruments to develop an online questionnaire:
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– The MBI-human service survey (MBI-HSS)1 which is a standardized instrument to measure burnout. It utilizes 9 items related to emotional exhaustion and it is most frequently used in healthcare research. A score of 27 and more signals a high burnout level.
– The Leadership scale, which assesses staff discernment of managers’ leadership attitude3. It is based on a 7-point Likert scale 11-item questionnaire that considers resolving conflicts with others, autonomy in decision-making, and staff involvement in development.
Conclusions: Everyone is at risk of burnout in the ICU setting. Implementing the empowerment hypothesis among the ICUs in Qatar could enhance the managerial preferences in the hospitals dealing with a wide spectrum of healthcare practitioners.
Empowerment is symbolized by energizing the practitioners5 and as the awareness of burnout is increasing, proper interventions should be directed at adequate orientation, early recognition, and dealing with the predisposing factors to prevent future occurrences. The findings of this study could widen the scope of practitioners who could be involved through education in diagnosing and managing burnout.
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Weird and wonderful ICU cases: Unusual causes of shock
More LessDuring their practice, intensivists are ought to face challenging cases that are rare. Intensivists need to be aware of the rare causes of shock beyond common presentations. In each category of shock, there are rare causes that require prompt identification and management. Certain clues in the patient's presentation might point to those rare causes.
Classically shock is classified into: distributive, hypovolemic, cardiogenic, and obstructive. In this era of bedside point-of-care ultrasound, intensivists are able to promptly identify the cause of shock and institute a resuscitation plan. However, there are cases when the diagnosis is still obscure and the cause of shock is not easily identified. For example, in a study of patients admitted with presumed septic shock, 7.4% had no identified cause of shock and 11% had sepsis mimickers.1
Hypovolemic shock occurs secondary to a reduction in the effective circulating volume secondary to fluid loss or third spacing. A rare cause of hypovolemic shock is idiopathic capillary leak syndrome (Clarkson Syndrome).2 The syndrome is characterized by recurrent episodes of rapidly progressive generalized edema, shock, renal failure and high hematocrit. The episode usually resolves in 3-7 days where the capillary leak resolves and a phase of pulmonary edema occurs. Several treatment options such as intravenous immunoglobulin (IVIG) and aminophylline were used in case reports.3
Vasodilatory shock occurs secondary to peripheral vasodilation and decrease in blood flow. It occurs as part of the systemic inflammatory response syndrome for which sepsis, acute pancreatitis, acute liver failure, and major trauma are common causes. Rare causes that need to be considered include: hemophagocytic lymphohistiocytosis (HLH), systemic mastocytosis, and toxic shock syndrome.
Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by macrophage activation and engulfment of hemopoetic cells which leads to pancytopenia. It is also characterized by cytokines storm that lead to a vasodilatory shock, multi-organ failure, and acute respiratory distress syndrome (ARDS). The most common triggers are infection, malignancy, and autoimmune diseases. Pointers to this diagnosis in the intensive care unit include: pancytopenias, hypofibrinogenemia, high triglycerides, and high ferritin. Treatment necessitates treating the underlying cause as well as using immune modifying therapies.4
Systemic mastocytosis is a rare cause of recurrent anaphylaxis shock. It results from the accumulation of mast cells in tissues and can present with anaphylaxis and vascular collapse. An important clue to the diagnosis is the presence of urticarial pigmentosa and the absence of an allergen history.5
Toxic shock syndrome is a unique cause of sepsis. It is caused by a pre-formed toxin produced by Staphylococcus aureus and Streptococcus pyrogenes. The clue to the diagnosis include the rapid onset after the precipitating factor, erythroderma, and skin desquamation. Treatment includes IVIG and Clindamycin.6
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Factors contributing to patients’ presentation to the emergency department of an academic hospital in Oman after leaving other hospitals against medical advice
More LessBackground: One of the reasons to leave against medical advice (LAMA) from a hospital is to seek treatment in another hospital1. Those patients are at high risk of readmission and mortality compared to patients with planned discharge2. The aim of this study was to identify the factors for patients' presentations to an academic tertiary hospital Emergency Department (ED) specifically after LAMA from another hospital and to investigate the outcomes of these presentations. Methods: We conducted a prospective cross-sectional study. We included all patients who presented to Sultan Qaboos University Hospital (SQUH) ED after LAMA from other hospitals in Oman during the six-month study period. We excluded patients who died during hospitalization, those who refused to give consent, and those who were identified only after their ED visits' by reviewing the ED medical records' and were difficult to be contacted. We asked the participants to fill a paper-based questionnaire to investigate the factors of their presentations to SQUH ED. We designed the questionnaire by reviewing the literature on second opinion, patient's satisfaction, and LAMA3–5. The questionnaire underwent a content validation by two experts. We investigated the outcomes of the presentations by reviewing the patients' medical charts. We used descriptive statistics to analyse the data. Results: A total of 112 patients presented to SQUH ED after LAMA from other hospitals. 94 of them participated, while 18 patients were excluded. There was equal male to female distribution among the participants and their mean age was 36.8 years (SD = 26.483). Figure 1 illustrates the previous hospitals where patients LAMA. The majority of patients (66.0%) were LAMA from governorate hospitals. Table 1 presents the factors of presentation to SQUH ED. The most common factor to present to SQUH ED (94.7%) was to get the quality of care delivered in SQUH. Out of 94 patients, 70 (74.5%) were admitted to SQUH. More than one-third of the admitted patients (35.7%) required management in critical care units. Conclusion: This study provides the factors that lead LAMA patients to choose an academic tertiary hospital for their second presentation. Identifying these factors can help the decision makers in the healthcare system in Oman to increase the quality of services in other healthcare facilities. Providing more healthcare facilities with diagnostic modalities like Magnetic Resonance Imaging (MRI) and in some places even Computed Tomography (CT) imaging may help decrease the incidence of LAMA. Also considering the addition of diagnostic and therapeutic units (for example: endoscopic suites and angiography suites) may allow for better health services in these hospitals and therefore minimize the occurrence of LAMA. Furthermore, allowing for and addressing the need for second opinion in some patients and organizing for that formally between different specialties in these hospitals may improve the patient satisfaction and therefore reduce the incidence of LAMA. Ultimately all the previously mentioned interventions can minimize the morbidity and mortality associated with LAMA. The study can also act as a pilot for larger multicentered studies.
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Nutritional management of critically ill patients: outcomes associated with the implementation of a clinical dietetic service within a high-volume intensive care unit
More LessBackground: The provision of nutritional support among critically ill patients is complex and multifactorial.1 There is a gap in the literature around the optimal amount of energy and protein critically ill patients require.2 There has been a direct association with malnutrition and morbidity and mortality among critically ill patients.3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients.3 Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.4 Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.5
Al-Adan Hospital in Kuwait caters for a population of 1.2 million, accounting for one third of the Kuwait's population. Clinical dietetics in the intensive care unit (ICU) at Al-Adan Hospital is an integral part of the multidisciplinary team and is deeply imbedded in the overall service. The dietetic model of care is proactive in nature and focuses on individualized patient care upon admission. Providing optimal nutritional support for critically ill patients extends beyond selecting the most appropriate formula and calculating caloric requirements. There has been a shift in the goals of care from “supportive nutrition” to “therapeutic nutrition”.5 The main objective of the dietetic service is to meet energy targets, preserve lean body mass, manage metabolic complications, and maintain patient immune function. Aim: This study will present recommendations for clinical practice and discuss outcomes associated with meeting nutritional targets. Methods: It is based on a literature review of existing guidelines, randomized controlled trials, and various meta-analyses examining the data available around nutrition in critically ill patients. Additionally, a description of a nutrition-focused model of care along with a retrospective analysis of routine data at Al-Adan Hospital ICU will be presented. Results: It is challenging to predict energy expenditure and energy requirements among critically ill patients. The current golden standard of care is indirect calorimetry however, its application among patients with altered gas exchange is debatable. Multiple studies have shown that there is a high rate of unintentional underfeeding among ICU patients due to feeding interruptions during procedures. In reviewing outcomes of 300 patients at Al-Adan Hospital, meeting the nutritional needs of patients throughout their ICU admission has shown to reduce the risk of infection and overall mortality (p ≤ 0.05) (See Table 1). Additionally, an association was observed between feeding intolerance and length of stay (p = 0.031). Conclusion: Observational data has demonstrated a positive association between meeting protein needs and survival. Applying a nutrition focused model of care within the ICU has clearly impacted on patient outcomes. Further research in the form of prospective randomized controlled trials exploring the optimal dose and time of nutritional therapy is necessary to examine nutritional needs of critical care patients.
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Hyponatremia induced compartment syndrome of all extremities: Case report and review
Authors: Nissar Sheikh, Gulzar Hussain, Arshad Chanda and Shakeel RaizBackground: Compartment syndrome is a well-recognised complication from trauma, burns, orthopaedic, vascular, or other surgery of the limbs. Hyponatremia related rhabdomyolysis leading to compartment syndrome of all four extremities with renal and hepatic impairment is rare.1,2,3 Although the rhabdomyolysis can occur without hyponatremia. Young men have the highest incidence of compartment syndrome, particularly after long-bone extremity fractures and strenuous exercise.4,5 We present a case of compartment syndrome of all four extremities following a brief episode of recreational jogging. Case: A 39-year-old Indian male, known hypertensive on nifidipine and indapamide was presented to the emergency department with generalized weakness, lower leg pain and cramps for 3 days. He had jogged for 2 km in warm temperatures. His symptoms worsened and he was unable to walk. Other complaints were headache, pain in both arms, and passing dark coloured urine for two days. Both his calf muscles were tender, tense to feel, and painful on flexion and extension. Dorsalis pedis pulses were weak but palpable bilaterally. Capillary refill was less than three seconds and sensation were intact in both lower limbs. Oxygen saturation of toes on both feet was 99%. Other body systems were unremarkable. His respiratory rate was 20 min− 1, blood pressure 210/110 mmHg, temperature 36.6°C, oxygen saturation (SpO2) 99%. Initial biochemistry results were serum creatinine 142 umol.l− 1, myoglobin 5791 ng.ml− 1, creatinine phosphokinase 19032 U.l− 1, sodium: 124 mmol.l− 1, aspartate aminotransferase (AST) 167 U.l− 1, and alanine aminotransferase (ALT) 49 U.l− 1 (Table 1). Doppler ultrasound of leg vessels showed no evidence of deep venous thrombosis, echogenicity of the muscles in the thigh and lower leg appeared within normal limits. Rhabdomyolysis was diagnosed and rehydration begun with Hartman's solution 1000 ml followed by 125 ml.h− 1. The patient was admitted to the ward for continued hydration and analgesia to treat the pain. His leg pain worsened overnight despite intravenous analgesia. His pulse in both feet became feeble and renal and hepatic function worsened. Compartment syndrome was suspected and orthopaedic surgery was consulted. He had an emergency fasciotomy of all compartments and in all four limbs. Post-procedure pulse oximetry of digits and toes had a 99% saturation, but peripheral pulses remained weak. He was able to move fingers of both hands, but had no movement of his ankles and toes. The patient was transferred to the intensive care unit (ICU) for further management. His maintenance intravenous fluid was changed to 0.9% sodium chloride due to persistent hyponatremia. His wounds were re-explored and debrided on the fifth post-operative day. Wounds culture were growing pseudomonas aeruginosa that was treated with Meropenam according to the sensitivity. Six sittings of wound debridement and irrigation were performed. Over two weeks his renal function, liver function, and serum sodium concentration normalised (Table 1) without requiring renal replacement therapy. He was transferred to the ward on day 16 and discharged home to be followed in outpatient clinic. Conclusion: Physical exercise in the presence of hyponatremia can cause rhabdomyolysis and compartment syndrome of all extremities leading to multi-organ failure.
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Analgesic sparing effects of Dexmedetomidine in surgical intensive care patients
Authors: Nissar Sheikh, Arshad Chanda, Saher Thaseen, Zia Mahmood, Adel Ganaw and Nabil ShallikBackground: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm.
Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.
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A rare case of propofol related infusion syndrome in a neurosurgical patient
Authors: Ranjan M. Mathias, Nissar Shaikh, Arshad Chanda, Qazi Zeeshan and Shakhsanam MirishovaBackground: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5
Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure.
Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg.
His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours.
He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications.
Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.
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Safety of prone positioning in critically ill patients
Background: During the past two years, 5% of patients admitted to the Medical Intensive Care Unit (MICU) of Hamad General Hospital (HGH) had severe acute respiratory distress syndrome (ARDS) with a PaO2/FiO2 ratio less than 100 mmHg. The risks associated with this condition include ventilator associated lung injury, over distension of lungs, and poor gas exchange which results in increased morbidity and mortality. With quality improvement initiatives like prone positioning, the mortality and morbidity associated with severe acute respiratory syndrome1 can be reduced by improving hypoxemia2 with a significant enhancement in PaO2/FiO2 ratios while reducing injurious ventilation. Also, prone positioning can help prevent invasive interventions such as placing patients on extracorporeal membrane oxygenation (ECMO) therapy.3Methods: We evaluated the safety of prone positioning for improving hypoxemia in critically ill patients with PaO2/FiO2 ratio < 100 mmHg to PaO2/FiO2 ratio < 200 mmHg from 1st January 2017 to 31st December 2018, without major complications. Data collected included the PaO2/FiO2 ratios based on arterial blood gases of mechanically ventilated patients before and after prone positioning.
We were able to facilitate prone positioning in 72 out of 110 patients with severe ARDS having a total average PaO2/FiO2 ratio of 84.4 ± 30 mmHg. The patients were proned for a maximum of 16 hours in each session where up to three sessions were incorporated. No major complications were encountered during the proning sessions. This was thought to be accomplished through the coordination of a dedicated multidisciplinary team, education and simulation classes for physicians, nurses, and respiratory therapists, following appropriate inclusion and exclusion criteria for prone positioning, and implementing quality measures through Plan-Do-Study-Act (PDSA) cycles as represented in Figure 1. Results: The total average PaO2/FiO2 ratio before proning for 65% of patients (n = 72) with severe acute respiratory distress syndrome4 was 84.4 ± 30 mmHg and after one hour of 16 hours proning, it improved to 180.3 ± 78 mmHg. The remaining 35% of patients either had traumatic fractures, unstable spinal injury, severe hemodynamic instability, or morbid obesity together with ARDS which made them unfavorable for prone positioning. Out of those who were proned, 11 (12.5%) patients did not have improvement in oxygenation after proning due to non-recruitable lungs and were put on ECMO. The PaO2/FiO2 ratios before and after one hour of implementing the prone position technique in each quarter of 2017 and 2018 are represented in Figure 2. Conclusion: In patients with severe ARDS, prone positioning proves to be a safe practice and leads to improvement in hypoxemia without major complications. Our future prospects with respect to prone positioning include the following:
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• Sustaining and standardizing the accomplished work of data collection.
• Implementing the prone positioning technique across other critical care units of Hamad Medical Corporation.
• Keeping a record of minor complications associated with prone positioning and resolving them in further sessions.
• Documenting cases with contraindications to prone positioning.
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Towards next generation cannulation simulators
Background: Cannulation, in extracorporeal membrane oxygenation (ECMO), is the act of inserting a cannula through the body1. For femoral veins, femoral arteries, and the jugular vein, the cannula stops at the inferior vena cava (IVC) beside the hepatic vein and at the beginning of the distal aorta, and the superior vena cava at the right atrium, respectively. Cannulation is considered a critical operation and requires intensive training. Simulation-based training (SBT) is the gold standard, allowing for training in risk-free, versatile, and realistic environments2. A research collaboration was established between Hamad Medical Corporation and Qatar University College of Engineering to support the development of the ECMO training programme. Initially an ECMO machine simulator was developed with thermochromic ink to simulate blood and modules that simulate common emergencies practitioners may face during ECMO runs3. This cannulation simulator is now being designed to close the gap in the market in relation to cost and fidelity4,5. Methods: The cannulation simulator is composed of several modules. Firstly, a 3D-printed femoral pad mold was constructed to facilitate the production of cannulation pads (Figure 1(a), (c)). Secondly, cannulation pads were designed so they are anatomically correct and ultrasound compatible. For the arteries, the superficial artery was added at the access point to simulate possible incorrect routes for the cannula. Furthermore, the orientation of the veins and arteries were set to further resemble the human anatomy, where the arteries are situated above the veins (Figure 1(a), (b)). In addition to the implementation of a closed loop linking the jugular to the femoral, cannulation access points with a pump connected to a tank between them to regulate the flow. The blood flow in the arteries was enhanced with a pump to simulate a pulsatile flow while the flow in the veins is laminar as seen in the single loop implementation (Figure 1(h)). The connection of the pump to the embedded system is shown in Figure 1(g). The junctional point in the IVC was designed in the venous loop to allow for two cannulas to pass and an alternative path simulating the renal vein was added. A force sensing resistor (FSR) was connected to detect and measure incorrect entry of the guide-wire as this, in real-time scenarios, could cause internal bleeding to the patient (Figure 1(g)). Lastly, the Y-connector showing the renal vein entry is shown in Figure 1(d) and (e). Results: Tests were done on the system namely on the FSR to recalibrate it in the presence of liquid. Tests on the pulsatile flow were conducted to optimize for realism in terms of pressure. Since both jugular and femoral cannulation access points are included, the simulator can be used for training for all ECMO modes including veno-arterial and veno-venous. After testing, the main limitations of the current prototype include the flexibility of the tubes, limits on FSR measurements, and the rigidity of the available 3D printing material. Conclusion: After implementing the stated features, the anticipated outcome is a realistic and cost-efficient ECMO cannulation simulator.
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Incidence, risk factors and outcome of delirium in a surgical intensive care unit of a tertiary care hospital
Authors: Asghar Ashraf, Madiha Hashmi, Amir Raza, Bushra Salim and Muhammad Faisal KhanBackground and Objective: Delirium in critically ill patients is common and distressing.1 The incidence of delirium in intensive care units (ICU) has been reported to range from 45-87%.2,3 Arguably, delirium is a well-recognized cause of morbidity and mortality among ICU patients. It can lead to longer hospital stays, lower six-month survival, and cognitive impairment persisting even years after discharge.3 It has therefore been recommended that all ICU patients are assessed for delirium using a validated tool.3 To date, limited data is available on the prevalence of delirium in surgical patients. In a study published in 2008, the observed risk was 73% in surgical and trauma patients.4
This study aimed to evaluate the incidence and modifiable risk factors of delirium in the surgical intensive care unit (SICU) of a tertiary care hospital in a developing country. Methods: We conducted a prospective observational study in patients over 18 years of age who were admitted to the SICU for more than 24 hours in Aga Khan University Hospital, Pakistan, from January 2016 to December 2016. The SICU has 9 beds and is run by trained intensivists with 24/7 coverage. Nurse to bed ratio is 1:1. Admissions are received from the emergency department, operating room, and surgical wards. After approval from the University's ethical review committee, written informed consent was taken from the patient's next of kin. Patients who had a preexisting cognitive dysfunction, signed a Do-Not-Resuscitate order, or stayed in the SICU for less than 24 hours were excluded from the study. Delirium was assessed by the Intensive Care Delirium Screening Checklist (ICDSC).5 The incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors.
Results: The average patient age was 43.29 ± 17.38 years and BMI was 26.25 ± 3.57 kg/m2 (Table 1). Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. In univariate analysis, chronic obstructive pulmonary disease (COPD), fever, pain score >4/10, agitation, sedation, hypernatremia, length of ICU stay ≥ 7 days, and mortality were significantly higher in patients who developed delirium (Table 2). Patients on midazolam and propofol were four times more likely to develop delirium. Patients on pethedine were also more likely to develop delirium. Multivariable analysis showed that COPD, pain score >4, and hypernatremia were strong predictors of delirium (Table 3). Midazolam [aOR = 7.37; 95% CI: 2.04-26.61] and propofol exposure [aOR = 7.02; 95% CI: 1.92-25.76] were the strongest independent delirium predictors while analgesic exposures was not statistically significant to predict delirium on multivariable analysis. Conclusion: Delirium assessment is taken seriously and has been done for a long period of time in our unit. Our lower indicence rate of delirium concerns only the surgical patient population and reflects different assessment modalities used as well as pharmacological and non-pharmacological therapeutic options in comparison to the traditional approaches. In addition, we use different strategies such as bundles, sedation and pain protocol, and appropriate family interactions with the patients to minimize delirium. Delirium is a significant risk factor of poor outcome in SICU. This study showed an independent association between inadequate pain control, sedative medication, COPD, hypernatremia, and fever in developing delirium.
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Risk factors for severe bronchiolitis among children in the emergency department at Sultan Qaboos University Hospital
Authors: Maitha S. Al Asmi and Abdullah Al ReesiBackground and Aim: Bronchiolitis is an acute viral lower respiratory tract infection. It is a common disease among children below 2 years old, resulting in frequent presentation to the emergency department and occasionally admission1. For proper management of such patients, studying the disease spectrum and the risk factors is important2. The aim of this study was to investigate the demographics and risk factors for severe bronchiolitis in children (0–2 years old), in the emergency department (ED) at Sultan Qaboos University Hospital (SQUH). Methods: We conducted a retrospective cohort study, including children ( < 2 years old), who came to the ED with a presentation suggestive of bronchiolitis. We reviewed the charts for a two-year period (January 2015–December 2016). Demographic and baseline characteristics were gathered from electronic medical records and then analyzed. We categorized patients into severe and non-severe bronchiolitis according to the guidelines set by the New South Wales (NSW) Ministry of Health in Australia in 2012 for the “Acute Management of Bronchiolitis in Infants and Children”3. Therefore, in our study children who were considered to have severe bronchiolitis had one of the following: unwell appearance, apneas, severe tachypnea (>70 breaths/min), bradypnea ( < 30 breaths/min), moderate to severe grunting, cyanosis, pallor, oxygen saturation < 90% in air (or < 92% in O2), tachycardia (>180 beats/min) and difficulty in feeding (taking less than 50% of normal feed).
We investigated the following risk factors to predict severe bronchiolitis: maternal age, birth weight, prematurity ( < 37 weeks of gestational age), age < 12 weeks, congenital heart defects, congenital respiratory diseases, immunodeficiency, and global developmental delay. We described the cohort using descriptive statistics and performed a logistic regression analysis to determine the risk factors for severe bronchiolitis. Results: Of the 235 children with bronchiolitis, 133 had severe bronchiolitis while 102 had the non-severe form of the disease, with a greater percentage of males than females in both groups. The majority of children with severe bronchiolitis were in the age < 3 months group (32%), while the least was in the ≥ 12 months age group (10%). There was a trend toward statistically significant results for the following factors: chronological age < 12 weeks (OR = 2.67, 95% CI = 0.89–2.67), congenital cardiac diseases (OR = 2.12, 95% CI = 0.85–5.30) and congenital respiratory diseases (OR = 1.86, 95% CI = 0.80–4.27).
The following factors were associated with severe bronchiolitis using stepwise logistic regression: increased heart rate (OR = 1.046, 95% CI = 1.026 – 1.066), decreased SpO2 (OR = 0.890, 95% CI = 0.827 - 0.957), male gender (OR = 2.248, 95% CI = 1.105 – 4.573), irritability (OR = 2.209, 95% CI = 1.024 – 4.769) and global developmental delay (OR = 3.5, 95% CI = 1.0 – 12.537). Conclusion: Multiple factors were associated with severe bronchiolitis and three were trending toward significant association including the younger age group, presence of congenital heart and respiratory diseases4. Low saturation, tachycardia and irritability were both part of the diagnostic criteria for severity and risk factors which confirms the clinical importance of these factors. Further investigations with a prospective study and a bigger sample size are required to confirm our findings and find other associated factors.
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Reflective learning conversations as an approach for clinical learning and teaching in critical care
Authors: Emad Almomani, Tawfiq Alraoush, Omar Saadah, Ahmed Al Nsour, Megha Kamble, Jisha Samuel, Karim Atallah and Emad MustafaBackground: Reflective practice has become an integral element in healthcare and education.1,2 Hamad Medical Corporation (HMC) is the largest healthcare organization in Qatar and it aims to: develop highly competent healthcare practitioners, promote nurses’ critical thinking, enhance the implementation of evidence-based practice, encourage deep learning approaches, create positive learning environments, maintain patient safety, and bridge the gap between theory and practice in the critical care clinical settings.3 To achieve this, in 2015, reflective learning conversations and debriefing educational methods have been introduced by the HMC Nursing Education and Research Department. Methods: The HMC critical care education team introduced a new one-hour Continuing Professional Development (CPD) educational activity under the title of “Reflective learning conversation and debriefing”. This educational activity has been officially added to the critical care monthly and annual education plans and calendars. The reflective and debriefing discussion aims to give the chance for the critical care practitioners to share their real clinical experiences.1,2,4,5 The critical care nurses of HMC attend each session in a group of 5-7 clinicians and they are asked to reflect critically on a real clinical cases in relation to challenges, limitations, pitfalls, and improvement plan.2,5 A facilitator with a clinical and educational background facilitates the discussion and nurses are encouraged to summarize the learning lessons from that experience in addition to the recommendations and action plans which will be decided accordingly. This is then disseminated and shared with other healthcare facilities if it fits their scope of service. The reflective learning conversation and debriefing guidelines and protocol were established by the corporate nursing education team and are available to clinicians and facilitators (Table 1). Results: Reflective learning conversation with a debriefing improves nurses and health care practitioner's critical thinking and competency level which was evident by learners’ feedback and clinical competency assessment (Table 2). Furthermore, that educational activity is an attractive teaching and learning method to create dynamic learning environments in the critical care clinical settings which was evident by learners and facilitators’ feedback (Table 2). Moreover, nurse empowerment and active engagement were enhanced and encouraged by applying that educational method which was evidenced by the clinical experts’ feedback (Table 2). Finally, applying that method was effective to enhance evidence-based practice and patient safety in critical care settings (Table 3). Conclusion: Reflective learning conversations and debriefing has been perceived to be an effective learning method. Healthcare practitioners can learn from errors and previous experiences to avoid future mistakes in clinical practice. Sharing clinical experiences provides a medium to discuss cases from different angles and in depth which helps to promote deep learning, evidence-based practice, active learning, and patient safety. The recommendations of reflective learning conversations and debriefings can be applied and utilized to change current practice toward best practice and are applicable in all clinical domains and specialties. Although currently attended only by nurses, such sessions would be even more beneficial if attended by multiple professions.
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Qatar National Paediatric Sepsis Program: Where are we?
Authors: Ahmed Labib and Rasha AshourBackground: Sepsis and septic shock are medical emergencies and necessitate early and timely recognition and intervention. Failure of early recognition can lead to significant deterioration and may unfortunately culminate in death.1,2 Young people are considered at high risk of sepsis.3,4
Despite hundreds of trials and a multitude of approaches, an effective and efficient sepsis-cure agent does not exist. Most research into sepsis management has ended with non-conclusive and sometimes confusing results. Current evidence recommends a bundle of simple interventions to be accomplished as soon as possible and preferably within the first hour of sepsis recognition.2,5
A number of international initiatives aim at reducing sepsis mortality.2 Recently the World Health Organization (WHO) urged governments to set national mechanisms to tackle sepsis. A nation-wide sepsis program was developed to improve sepsis care for people in Qatar. A parallel National Paediatric Sepsis Program was developed to provide appropriate guidelines, education, a unified national care pathway, and to increase awareness of paediatric sepsis. Here we discuss the design and outcome of the Qatar paediatric sepsis program to date.
Methods: The program aims for early sepsis recognition and 95% compliance with the Sepsis Care Bundle by the end of 2019. To achieve this target a multi-faceted approach to paediatric sepsis care across all public healthcare sectors in Qatar was adopted. This includes Sidra Medicine and Hamad Medical Corporation and its Paediatric Emergency Centres.
An overarching system-wide sepsis committee was established and included major stakeholders within emergency medicine, critical care, infection prevention and control, and infectious disease and clinical laboratory. A paediatric multidisciplinary sepsis committee was established in 2017 and the National Paediatric Sepsis program was developed.
International evidence-based Institute for Health Improvement (IHI) methodology was adopted for program development. Major areas of the program were dedicated to the formulation of clinical practice guidelines, standardised care pathway, standardised EMR order set for all clinical areas, and ongoing education and awareness for healthcare providers at all facilities.
Sepsis simulation sessions were conducted to fill knowledge gaps and an improvement ramp module was included based on the PDSA (Plan-Do-Study-Act) strategy. A number of other PDSA initiatives were undertaken and included the following: Establish the paediatric sepsis clinical pathway and guideline (Figure 1); introduce the sepsis watchers’ concept to daily safety huddle; provide a standardized paediatric sepsis diagnostic kit; create unified paediatric sepsis antibiotics kits for all units with a safe first dose preparation protocol; develop and implement an e-learning module with education materials and paediatric sepsis order set in the electronic system.
Ongoing data collection and performance evaluation for sustainability and dissemination of information demonstrated the following:
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1. Paediatric sepsis incidence varies per facility and over time. Between 30 to 100 cases/month (Figure 2).
2. Recognition: Percentage of Clinical Review, Rapid Response Team (RRT) activation, and sepsis alerts that were appropriately escalated is 91%.
3. Order set use: 26% initiating the well-established electronic paediatric sepsis golden-hour order set.
4. 42% bundle compliance (Figure 3).
5. IV antibiotics within 60 minutes of time zero showed 81% compliance.
Conclusion: Current literature suggests that systemic and supervised implementation of an evidence-based pathway for suspected and confirmed paediatric sepsis saves lives. Our data demonstrated poor bundle compliance but significant improvement is seen in the areas of early recognition and antibiotic administration within one hour. Education and awareness are key to improve performance.
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Mortality of ischemic stroke patients admitted to the intensive care unit in Sultan Qaboos University Hospital
More LessBackground: Haemorrhagic and ischemic stroke is the second most common cause of death worldwide, with more than 10 million cases each year1. Hypertension, diabetes mellitus, smoking, hyperlipidemia, and aging are the most common risk factors of this cerebrovascular disease2. Mortality and disability increase with the complications experienced during the early phase of stroke, such as infection, seizures, and thromboembolism3. The intensive care unit (ICU) is the most appropriate treatment environment for stroke patient care in developing countries4. Aims: The aims of this study were to determine the ICU and in-hospital mortality of ischemic stroke patients admitted to the ICU within 24 hours of hospitalization, and the factors that determine and affect the outcomes of ischemic stroke to predict patients requiring early ICU admission. Methods: This is a retrospective study looking at the data of patients admitted to the intensive care unit in Sultan Qaboos University Hospital (SQUH) with an ischemic stroke diagnosis within 24 hours of hospitalization from 1st January 2013 to 31th December 2017. Results: There were 37 patients admitted to the ICU immediately from the emergency department because of ischemic stroke during the study period. There were 14 patients who died in the ICU, 2 died in-hospital after discharge from ICU, and the others were discharged from hospital (Table 1). There were 21 male patients and 16 females, with a mean age of 61.05 years. Most patients had comorbidities and risk factors that lead to poor outcome, the most common being diabetes mellitus (70.3%) and hypertension (67.6%). However, there was no association between blood pressure and glycemic control on admission with outcome (chi-square test, p = (0.667), (0.505) respectively). CT, MRI, and CT angiography are the most common diagnostic imaging tools used for ischemic stroke. We classified CT brain findings on admission according to the location of infarction. Middle cerebral artery infarction was present in 40.5% of the patients, 18.9% had other cerebral infarction, 10.8% had brain stem infarction, and the same proportion of patients had lacunar infarction, and the rest showed no abnormality. The two main reasons for admission to ICU were coma (73.0%) and neurological monitoring post-thrombolysis (24.3%). The rest were admitted because of respiratory failure. In ICU, 48.6% received intravenous thrombolysis and the majority of patients were discharged. Others were out of the therapeutic window and had a high chance of haemorrhagic transformation. Patients developed complications after ICU admission as shown in Figure 1. There was a significant association between ICU mortality and ICU complications, (chi-square test, p < 0.05). Conclusion: The mortality of ischemic stroke patients admitted to ICU within 24 hours of hospitalization in the study period was 43.2% with higher prevalence among older and male patients. The majority of these patients had comorbidities and risk factors that lead to a poor outcome. The main two reasons for admission to ICU were impaired consciousness and neurological monitoring post-thrombolysis. The outcome can be improved by preventing such complications and therefore reducing ICU mortality. More studies are recommended to find more factors that can predict the outcome of ischemic stroke.
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Pre-hospital use of capnography during emergency sedation analgesia
Background: Providing optimal patient care in the challenging, uncontrolled, and sometimes hostile pre-hospital environment may require the use of potent analgesics and sedatives. During pre-hospital emergencies, narcotics or sedatives administered for sedation, anxiolysis, or analgesia to allow the patient to tolerate unpleasant procedures, such as traction splint application, can result in cardiovascular and respiratory adverse events.1 Early recognition of poor oxygenation may prevent unnecessary patient hypoxia. The European Society of Anaesthesiology and the American Society of Anaesthesiologist mandate continuous capnography, in addition to standard monitoring which include pulse oximetry, 4-lead ECG, blood pressure, and heart rate measurements.1,2 Capnography refers to the non-invasive measurement of the partial pressure of carbon dioxide (CO2) in exhaled breath. Monitoring respiratory status provides early warning, thereby allowing clinicians to intervene before the onset of respiratory depression, potentially leading to bradypnoea, apnoea, hypoxia, and death.3 In addition, late identification of respiratory failure may lead to unnecessary endotracheal intubation and mechanical ventilation, increasing risk of protracted hospital stay and associated hospital-acquired infections.
Oxygenation and ventilation must be measured in both intubated and spontaneously breathing patients. While clinical indicators like chest rise or the plethysmography-derived respiratory rate can be used, monitoring the capnographic waveform for hypopnoeic and bradypnoeic patterns provides the clinician with a quick, accurate indication of acute adverse respiratory events.4 In two randomized trials, patients monitored with capnography in addition to standard of care, experienced significantly fewer episodes of hypoxia than those monitored without capnography.3,5 Hamad Medical Corporation Ambulance Service (HMCAS) in Qatar introduced a new clinical practice guideline (CPG) for safe sedation and monitoring in August 2017, mandating the routine use of capnography for all sedated patients. Safe sedation is achieved when the patient's oxygenation, ventilation, or haemodynamic status is not negatively impacted by the sedation procedure. Methods: The study aimed to describe trends in the use of capnography and other monitoring modalities for patients receiving Ketamine, Fentanyl, or Midazolam. Retrospective quantitative analysis of an existing HMCAS medical records database linked to a Business Intelligence (BI) tool enabled direct analysis on the tool and via a linked Microsoft Excel® spreadsheet, reviewing all emergency cases from 1st January 2017 to 31st December 2018. Frequency analysis and measures of central tendency was applied to the relevant clinical variables. All patient and practitioner identifiable data fields were redacted and not reported on. Results: Oxygen saturation (SpO2) and blood pressure monitoring was used on all patients (n = 5157, 100%), 4-lead ECG was placed on 3710 (72%) patients, while capnography was used on 4096 patients (79%, range = 39% to 99%). Capnography usage steadily improved over the 24-month period, especially for patients receiving Fentanyl (Figure 1). Conclusion: There was a significant improvement in the use of capnography during monitoring of patients that received Fentanyl, Ketamine, or Midazolam, with the most significant improvement for patients receiving Fentanyl alone. Further studies are required to determine the impact of this improvement on actual adverse event frequency.
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Scoline apnoea and pregnancy: SICU experiences
Authors: Nissar Shaikh, Mohammed A. Imran, Muhammad Zubair, Moad Ehfeda and Firdous UmmunnisaBackground: Suxamethonium chloride (scoline) is a short acting depolarizing muscle relaxant; it was discovered early in the nineteenth century but not used in clinical practice until 1951.1 Scoline became a popular muscle relaxant due to its rapid onset of action, quick metabolism and hence shorter duration of action. It is metabolized by cholinesterase. Scoline apnoea was described within a few years of clinical use of Suxamethonium due to inherited or acquired deficiency of the cholinesterase enzyme resulting in prolonged muscle relaxation.2 Now scoline is used in prehospital and emergency intubating conditions, in pregnancy fetal distress or cord prolapse due to obvious advantages in these circumstances.3,4,5 The aim of our study was to investigate the trends and incidence of scoline apnoea in pregnant patients. Patients and methods: All patients admitted with scoline apnoea during pregnancy in the surgical intensive care unit of a tertiary healthcare facility were included retrospectively in our study. Patients demographic data, duration of apnoea and intubation, intensive care unit stay and trends of scoline apnoea were recorded. Results: A total of 32 pregnant patients post-lower segment caesarean section were admitted to the surgical intensive care unit during the study period. The indications for general anaesthesia in the majority of patients were obstetrical emergencies (n = 23, 71.87%), refused regional anaesthesia (n = 7, 21.87%), and required general anaesthesia after the regional anaesthesia (n = 2, 6.25%) patients. Twenty-nine (90.62%) patients received premedication with metoclopramide and sodium citrate (Table 1a). Thirty (93.75%) patients received reversal combination of neostigmine and atropine. Four (12.50%) patients received fresh frozen plasma (Table 1a). The mean age of the patients was 31.7 ± 6.4 years old (minimal age was 25 years), all patients belonged to ASA class 1 and the mean duration of apnoea time was 4 ± 2.5 hours. The duration of intubation was 6 ± 4.5 hours and the length of surgical intensive care stay was 1.2 ± 0.7 days (Table 1b).
As shown in Figure 1a, the majority of patients were found to belong to the age group of 31 to 35 years (n = 12, 37.5%), followed by 9 (28.12%) patients in the age group of 26 to 30 years. It was also found that the Qatari locals and Egyptians formed the majority nationality (n = 12, 37.5% and n = 7, 21.87%) of patients (Figure 1b). The overall Arab patient population had a higher incidence of scoline apnoea compared to the Asian group of patients.
All patients were found to have cholinesterase levels below 3500 units/litre (normal range varies from 5400 to 13,200 units/litres), which is less than 70% of the normal value (Figure 2a).
There was a decreasing trend of scoline apnoea patients in recent years. From 2013 to 2016, there were no patients admitted to SICU with scoline apnoea and in 2017, only one patient with scoline apnoea was admitted (Figure 2b). Conclusion: Scoline apnoea incidence and trend in our parturient population is decreasing. The majority of our patients received premedication and reversal medication which decreases the cholinesterase levels. The decreasing trend may be attributable to increased regional anaesthesia practice and frequent use of rocuronium.
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Life threatening perioperative arrhythmias and hypokalemia
Authors: Ranjan M. Mathias, Nissar Shaikh, Shakeel Riaz and Arif VallianiBackground: Perioperative arrhythmia is a common general anesthesia complication of cardiothoracic surgeries. Sudden or acute onset of life threatening perioperative arrhythmias are rare clinical events in non-cardiac surgical patients.1,2 Electrolytes imbalance, particularly hypokalemia and dyskalemia, is one of the main possible underlining cause for the occurrence of these arrhythmias.3,4,5 We present two cases of severe hypokalemia leading to life threatening cardiac arrhythmias in the post-operative period. Case 1: A 30-year old healthy female patient without significant past medical history had emergency laparoscopic cholecystectomy and appendicectomy. Pre- and intra-operative periods were uneventful. Her pre-operative potassium level was 3.7 mmol/L. 18 hours post-operatively, she suddenly developed palpitations and went into ventricular fibrillation (VF) cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated followed by defibrillation which reverted the heart to a sinus rhythm. She was transferred to the intensive care unit (ICU) sedated and connected to the ventilator. In ICU, her serum electrolytes showed severe hypokalemia (serum potassium level 2.2 mmol/L) (Figure 1) so she was immediately started on 20 mmol of potassium chloride (KCl) over 30 minutes through central venous catheter (CVC) with complementary intravenous fluids with KCl. In the next 36 minutes she had four episodes of VF requiring CPR and defibrillation with a positive outcome. She received amiodarone infusion as well as continuous KCl supplementation and calcium gluconate 2 g. She received 100 mmol of KCl in 6 hours and a total of 220 mmol of KCl in 24 hours, and then she became stable. She was extubated after 48 hours. Echocardiogram and cardiac conduction studies showed no pathological changes. Cardiac conduction studies (electrophysiology study - EPS) were normal. She was discharged home and followed in the outpatient clinic. Case 2: A 78-year old known hypertensive male patient on angiotensin converting enzyme inhibitors was admitted to intensive care unit (ICU) for observation after laparoscopic cholecystectomy. Pre-operative serum electrolytes were within normal range. After one hour he started to have tachycardia and then went into pulseless ventricular tachycardia requiring defibrillation. His serum electrolytes results showed severe hypokalemia (2.4 mmol/L) (Figure 1) so this was corrected by rapid potassium chloride administration through CVC and supplementation of KCl in intravenous fluids. After 10 minutes he went into VF requiring defibrillation and a bolus of amiodarone. In the next 20 minutes he had three more episodes of VF requiring CPR and defibrillation.
In six hours he required 90 mmol of KCl to reach a serum potassium level of 3.7 mmol/L. A total of 210 mmol of KCl was needed in 24 hours. He was extubated after 24 hours. He was transferred to the ward on day 3 and discharged home on day 6, and later followed in the outpatient clinic. Conclusion: Perioperative severe hypokalemia can lead to life threatening cardiac arrhythmias. Early recognition and aggressive correction through perioperative potassium supplementation is essential for better outcome. Daily potassium level assessment and supplementation should be done in the perioperative period.
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Post renal transplant acute myocardial infarction
Authors: Arshad H. Chanda, Nissar Shaikh, Aref Villani, Mohammad Aturahman and Marcus LanceBackground: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.2 Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.3 We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated.
In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications.
On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney.
He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.3
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Innovative curriculum design for learner-centeredness and eustress learning in critical care educational programs
Authors: Emad Almomani, Tawfiq Alraoush, Omar Sadah, Ahmed Al Nsour, Megha Kamble, Jisha Samuel, Karim Atallah and Emad MustafaBackground: Hamad Medical Corporation (HMC), Qatar, aims to be MAGNET accredited (Nurse Excellence Program) by the American Nurse Credentialing Center (ANCC), in addition to be an academic health center. For these accreditations it is required to establish specialty foundation courses1 and one of these courses is the Critical Care Foundation Program (CCFP) which was designed by HMC critical care and educational experts. During the planning and curriculum design stages, the scientific and planning committee had a thematic focus on; learner-centeredness, active learning, and eustress learning strategies2,3. Methods: Stressful learning has negative impact on achieving learning outcomes2,3. For effective implementation of learner-centeredness and eustress learning, the CCFP design embedded different interactive teaching and assessment strategies including but not limited to; case-based teaching, competency-based teaching, interactive group learning conversations, and demonstration workshops1,2,4,5. To get the CCFP certificates learners should attend the whole program. However, there is a clinical attachment (competency assessment) and the CCFP was designed as eight teaching days over 8 weeks (one day per week). The program design was planned purposefully as the critical care nurses are given enough time to go to the critical care clinical fields to do the competency assessment for related CCFP teaching topics. Eight hundred critical care nurses have attended CCFP over the last four years. During the program, learners were given a chance and appropriate time to consolidate their knowledge and skills, in addition to bridge the gap between theory and practice, and to become competent and specialized ICU nurses with normal and tolerable levels of stress (eustress)3–5. As per the Qatar Certified Healthcare Practitioner Continuing Professional Development requirement, all course participants completed an evaluation form, which we administered online and combined with the participants’ ability to download the program completion certificate. The data from the participants’ evaluation forms was reviewed by the course scientific and planning committee which then was used to make further recommendations. Results: The CCFP curriculum design was helpful and effective in controlling critical care nurse's stress level which was evident by learner's self-reporting feedback and assessment tools (Table 1). Moreover, the program design was effective for active learner's engagement which was evident by the learner's feedback, educational experts, and peer review reports (Tables 1 and 2). A total of 800 nurses underwent the critical care specialty competency assessment process, and they were signed off as competent in all the domains assessed. Conclusion: Eustress learning allocates the learner at the center of the learning process and provides better learning outcomes. The design of this teaching curriculum which integrates different modalities of teaching and assessment methods helps learners to be actively involved in the learning and assessment process. Considering flexible and evidence based assessment methods in addition to written exams is recommended to decrease stress among learners. Reflection, and competency clinical attachment are recommended teaching and assessment methods to decrease learning and assessment stress levels, and to promote the effectiveness of the learning and teaching process.
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Hyperglycemic hyperosmolar state causing multiple thrombosis
Authors: Adel E. Ganaw, Nissar Shaikh, Abraham Marcus and Dominique SoekarmanIntroduction: Diabetes mellitus is regarded as a pro-thrombotic state1. Extreme hyperglycemia and dehydration in the hyperglycemic hyperosmolar state (HHS) add to the risk for thrombo-ischemic events2,3. Lower limb ischemia and occlusion of the femoral arteries in HHS is a distinct association, but its development may be hard to recognize due to its infrequent occurrence in daily practice. Prompt recognition is important to prevent irreversible damage3,4,5. Case Presentation: A 50-year old female was admitted to the intensive care unit (ICU) with epigastric pain for 1 day. She reported no other medical conditions except hypertension. Clinical examination showed a fully conscious female who was severely dehydrated. Clinical and laboratory parameters on admission are represented in Table 1. Based on a glucose level >30 mmol/L and an osmolarity >320 mOsm/L, HHS was diagnosed. Other investigations (septic work up, chest X ray, and ECG) were normal. The patient received a total of 9 liters of 0.9% saline with insulin/potassium over 6 hours. Dalteparin was given subcutaneously (5000 IU daily). On the second day of admission signs of acute ischemia were noticed in the left upper and left lower limbs. An ultrasound doppler and CT angiography confirmed the occlusion of the left subclavian, left femoral artery and aortic arch thrombosis (Figures 1A). Echocardiography showed a thrombus in the aortic arch. An emergency thrombectomy of the brachial and femoral arteries and a left arm fasciotomy took place and therapeutic unfractionated heparin infusion was started. A thrombophilia work up for antiphospholipid syndrome, heparin induced thrombocytopenia, complements 3 and 5, antinuclear antibody (ANCA), lupus screen, homocysteine, antithrombin, Factor V leiden, anticardiolipin, anti-B2 glycoprotein, protein S and C activity were normal. The patient and the family denied a personal or family history of thromboembolic events. On the fifth day post-admission, the patient developed septic shock with multi-organ failure (circulatory, respiratory, renal, and coagulation). The patient responded to ICU management. Parameters of her coagulation profile are given in Table 1. On the ninth day the patient developed dry gangrene in the left foot, which required a below the knee amputation. On the eleventh day the patient was extubated, neurological assessment was showing right-sided hemiparesis. The MRI was showing multiple microcerebral hemorrhages, an infarction in the left paramedian pons and a cerebellar infarction (Figures 1B). On the fourteenth day the patient developed abdominal distension. The CT showed partial mesenteric vein thrombosis despite the patient being on therapeutic heparin (Figure 2). On the seventeenth day the patient had a tracheostomy and was discharged from the ICU for rehabilitation on a therapeutic dose of dalteparin. Conclusion: Current guidelines provide for thromboprophylaxis in HHS, i.e., heparin during admission. This covers the risk for deep venous thrombosis (DVT), but might be insufficient in case of an imminent arterial thrombosis, especially in cases of long existing diabetes.
Alternative therapy targeting crucial factors in the coagulation pathway leading to an arterial thrombus should be searched. The development of an algorithm for thromboprophylaxis in a hyperglycemic crisis needs our attention to improve the outcome of this high-risk condition.
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Unexpected complication of a common therapy in a pregnant patient
Authors: Adel Ganaw, Nissar Shaikh, Moad Ehfeda, Raphael Samuel and Firdous UmmunnisaBackground: Pre-eclampsia/eclampsia is a life-threatening disease with considerable risks on maternal and neonatal health. Globally, it affects between 2–8% of all pregnancies. Worldwide, approximately 63,000 pregnant women die each year due to pre-eclampsia/eclampsia. The MAGPIE (Magnesium sulphate for Prevention of Eclampsia) trial stated that the risk of developing convulsions was lowered significantly (58%) in severe pre-eclampsia patients who received magnesium sulfate in comparison to the placebo group.1 The exact mechanism of action of magnesium sulfate (MgSO4) is not completely understood, blocking calcium channels and decreasing availability of calcium for smooth muscle contractions has been suggested. Pritchard advocated that therapeutic concentration of MgSO4 should be between 2-4 mmol/l.2 Despite strong evidence of the effectiveness of MgSO4, concerns have been expressed about the risk of hypocalcemia to the patient when used alone or concomitantly with nifedipine as both of them affect calcium metabolism.3 Hypermagnesemia causes hypocalcemia by inhibiting parathyroid hormone secretion and increases urinary excretion of calcium. Severe hypocalcemia is a life-threatening condition and may lead to focal or generalized tonic muscle cramps, convulsions, arrhythmia, and laryngospasm and stridor which is common in the pediatric population but has also been reported in adults.4 A case of symptomatic hypocalcemia secondary to hypermagnesemia is extremely rare, and to the best of our knowledge, only a few cases have been reported.5 We believe this is the only case in the literature with stridor and potential airway obstruction. Case: A 30-year old black South African woman, gravida 5, para 3+1, presented with severe preeclampsia (BP 215/145 mmHg, proteinuria +2), and preterm premature rupture of membrane at 33 weeks of gestation. General and obstetric examinations were unremarkable. Laboratory parameters on admission showed acute kidney injury, anemia and elevated lactate dehydrogenase and alkaline phosphatase. Other investigations were normal (Table 1). She was admitted to the high dependent unit and received 10 grams of intramuscular MgSO4, followed by continuous intravenous infusion at a rate of 2 g/hour for 24 hours. Her blood pressure dropped to 145/95 mmHg. Three hours post-admission, her blood pressure raised to 186/124 mmHg and was controlled with a labetalol intravenous infusion and nifedipine 10 mg orally. Her blood pressure then dropped to 150/90 mmHg. Six hours post-admission, the patient had an uneventful emergency caesarean section under spinal anesthesia for fetal distress. Nine hours post-admission, the patient had dyspnea, respiratory distress, and inspiratory stridor, and chest examination was unremarkable. While checking her blood pressure, the patient had carpopedal spasm (Trousseau's sign) and masseter muscle spasm (Chvostek's sign). MgSO4 infusion was stopped. She received 10 ml of 10% calcium chloride over 10 minutes and responded dramatically to resuscitation and calcium chloride. Investigations (arterial blood gas, FBC, urea and electrolytes) were performed and showed low ionized calcium 0.89 mmol/l and her magnesium level was 2.74 mmol/l. Conclusion: Although MgSO4 is considered as the treatment of choice for the prevention of convulsions in pre-eclampsia/eclampsia patients, concerns have been raised regarding the risk of severe hypocalcemia, especially when used concomitantly with calcium channel blockers. Prospective studies designed in a controlled fashion are needed to assess the safe combination of magnesium sulfate and nifedipine.
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Do we have to tell the patient's family everything concerning organ donation?
Authors: Somaya Ibrahim and Kobra Mohammad ZareiBackground: Globally there have been many initiatives to enhance the number of organ donors.1 The number of individuals waiting for a transplant is significantly higher than the number of available donated organs and the gap continues to widen. In the United States, it has been reported that over 106,000 individuals are awaiting organ donation.2 The family plays a crucial role in the organ donation process. Therefore, it is important to understand the organ donation experiences of family members in the Arab world which extends from the Atlantic Ocean in the west to the Arabian Gulf in the east, and from the Mediterranean Sea in the north to Central Africa and the Indian Ocean in the south. There are some challenges surrounding organ donation due to ethical, legal, and social problems. Besides that, religious and traditional issues are more common in the Middle East and Gulf region. In the Middle East, organ donation after brain death or for living donors have less family members’ willingness and acceptance.3 Family members of organ donation cases face many challenges before accepting the terms of donation. In reference to this issue, many studies stress the need for family involvement, education and awareness programs in early stage of brain death, even in acute cases that are subject to time constraints.
We aim to examine findings of an integrative literature review and explore families’ decision-making process related to organ donation of brain dead patients or living donors, posing the question “Do we have to tell the patient's family everything concerning organ donation?” Answering this question will help healthcare providers to understand factors, barriers and culturally sensitive aspects that are leading to the willingness and acceptance of organ donation.4Methods: The integrative literature review was based on Cooper's five-stage process.5 These stages clearly summarized by Russell include problem formulation, data collection or literature search, evaluation of data, data analysis, and interpretation and presentation of results.6 To determine the sample of the review, published scientific papers in indexed periodicals electronic databases, such as CINAHL, Medline, Google Scholar with Full Text and PubMed from 2009-2019 were searched. Results: The result of the review highlighted the importance of different aspects that lead to acceptance of organ donation. We anticipate that the results of this review will increase awareness of the patients’ families concerning organ donation experiences and its impact on the decision-making process. In addition, it will help healthcare professionals and policymakers to consider new strategies, ways of thinking, and communication strategies that can be adopted with patients’ families concerning organ donation. Organ donation campaigns can help raise public and healthcare providers’ awareness of the benefits of such programs. Conclusions: This review identified that public orientation and family support is the ideal approach for family consent which often remains the only way for organ donation to be made possible. In addition to that, there is a need for the development of supportive policies and continuous education and training programs for healthcare providers and proper utilization of resources to improve the organ donation process.
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The use of screening tools in the early recognition of sepsis in the prehospital adult patient: a review of the literature
Background: Sepsis has been identified as a time critical and life-threatening condition resulting from the body's own systemic response to infection leading to multi-organ dysfunction and failure, and remains a major frontrunner in the morbidity and mortality of critically ill patients1–3. The 2016 Surviving Sepsis Campaign1 identified that similar to patients with polytrauma, stroke and acute myocardial infarction, the early identification and timeous delivery of appropriate treatment for patients with sepsis could improve patient outcomes and decrease mortality rates1,4. Prehospital sepsis screening tools could provide a systematic approach to critically ill patients in order to identify those patients with a high index of suspicion for sepsis and allow for early and aggressive management.
Methods: A literature review was conducted for the period January 2011 to September 2017. A database search was conducted via the electronic databases Ovid MEDLINE (without revisions), CINAHL and The Cochrane Library. The websites ScienceDirect, Wiley Online Library, British Medical Journal (BMJ) and Google Scholar were also used in the search for literature. Full search strategies are detailed in Table 1. The selection and rejection of all articles can be reviewed in Figure 1.
Results: All articles identified for full review (n = 13) were between the period January 2011 and September 2017. The three most common methodologies identified were systematic review (n = 3), prospective cohort study (n = 3) and prospective observational study (n = 3). Other methodologies included literature review (n = 1), retrospective cohort study (n = 1), retrospective analysis (n = 1), and retrospective cross-sectional study (n = 1). Through literature analysis, three main areas of interest were identified in which articles were reviewed: the early recognition of sepsis by Emergency Medical Services (EMS) staff (n = 2), the early recognition of sepsis using a prehospital sepsis screening tool by EMS (n = 6), and the impact of EMS sepsis recognition and management on patient outcomes (n = 4). A comparison summary of the various sepsis screening tools can be viewed in Table 2.
Conclusion: Previous literature has described EMS transport rates of approximately 3.3 sepsis patients per 100 and approximately 40% of septic patients admitted having been transported by EMS5. Despite this relatively high prevalence, the review identified that recognition of sepsis by EMS personnel was poor. The use of various sepsis screening tools showed improved recognition by EMS but validation studies on the accuracy of these tools is required. In patients in whom a screening tool was used and early pre-notification given to receiving facilities, a decrease time to definitive management of these patients was identified. These varied findings in outcomes of septic patients transported by EMS identifies the need for further studies on EMS recognition of sepsis and the impact it has on the outcomes of these patients. A specific prehospital sepsis screening tool could possibly assist in the early recognition of sepsis. Pre-notification to receiving facilities could allow the facility to prepare for EMS arrival and continue aggressive early goal directed therapy (EGDT) as required.
The author acknowledges the possibility of publication and selection bias within this review due to single author selection and only English studies being included.
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Effect of ivabradine on hospitalization of heart failure patients with reduced left ventricular ejection fraction: A retrospective cohort study
Authors: Sara Al-Balushi and Mohammed Fasihul AlamBackground: Diuretics, ACE inhibitors or ARB, beta-blockers, and aldosterone antagonists are well established guideline directed medical therapies (GDMT) used in patients with left ventricular reduced ejection fraction (LVrEF) heart failure (HF). Hospitalization is an important marker of poor heart failure prognosis1–2. Scientific reports have shown that ivabradine reduces cardiovascular outcomes (cardiovascular death and hospitalization due to worsening heart failure symptoms) in HF patients3. However, in the SHIFT trial 8% of the ivabradine study group were from Asia, with 3% from other races and Caucasians making up the majority of the sample (89%)3. No previous studies have investigated the effect of ivabradine on cardiovascular outcomes among Arabs and non-Arabs from Asia and Africa or Middle Eastern countries in general. The aim of this single-center retrospective study was to assess the effect of ivabradine in addition to GDMT in a group of HF patients with a heart rate (HR) of more than 70 bpm, LVrEF (EF < 40%) and New York Heart Association (NYHA) class II-IV, compared with another group of patients not taking ivabradine with HR of more than 70 bpm, LVrEF and NYHA class II-IV on GDMT. Methods: The study was a retrospective cohort study. It was conducted in the Heart Hospital (HH) at Hamad Medical Corporation (HMC) in Qatar. All patients registered in the HF clinic from April 2015 to September 2016 were enrolled in the study. They were either exposed or not to ivabradine (Figure 1). The primary outcomes studied were the associated risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was mortality due to all causes. Patients’ follow up records for 18 months after recruitment were observed. Baseline characteristics were collected at enrollment. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. The number of hospitalizations due to worsening HF was modeled using a Poisson regression model. Length of hospitalization (in days) was estimated and assessed between groups by a negative binomial regression. Results: The study included 111 patients (Figure 1): 37 (33.94%) ivabradine patients and 74 (66.67%) non-ivabradine patients. The number of ivabradine patients hospitalized were 23 (62.16%) vs 54 hospitalized non-ivabradine patients (72.97%) (OR 0.43, 95% CI 0.16-1.015, p = 0.094) (Table 1). Days of hospitalization for the ivabradine group were 464 (41.28%) vs 660 (58.72%) for non-ivabradine (IRR 1.63, 95% CI 0.79-3.38, p = 0.187). The death rate in ivabradine patients was three (two patients died due to CVD and one due to other causes) and it was also three in non-ivabradine patients (one due to CVD and two due to other causes). Testing the outcome by the factor of ethnicity instead of treatment group had different results. The number of Arabs admitted was 55 (78.57%) compared to 22 non-Arabs (53.66%) (chi-square, p = 0.006). The number of Arabs admitted in the ivabradine group 19 (76%) was significantly higher than for non-Arabs 4(33.33%) (Pearson chi-square, p = 0.012). Conclusion: The results of the study are not generalizable but showed that ivabradine patients with HFrEF along with GDMT had less risk of hospitalizations but lengthier stays and increased count of hospitalization compared to non-ivabradine patients. Though the study did not aim to explore the differences between Arab and non-Arab patients, significant differences were found in the statistical analysis highlighting the need for further research to investigate the reasons behind these differences.
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A systematic review for the role of systemic thrombolysis in intermediate-risk (submassive) pulmonary embolism
More LessBackground: Pulmonary emboli (PE) represents an extended spectrum of diseases. 10% of submassive PE progress to massive PE, and while overall mortality is around 5%, it can reach 30%,1 highlighting the potential severity of submassive PE. Treatment of low and high-risk PE is rather straightforward. However, treating intermediate risk PE is challenging due to the potential risks associated with aggressive therapy. We assessed the effect of adding thrombolytic therapy to standard treatment with heparin on short-term mortality, clinical deterioration, and bleeding in intermediate-risk PE cases. Intermediate-risk PE in this systematic review is objectively confirmed PE either by computer tomography (CT) or ventilation/perfusion (V/Q) scan in normotensive patients (systolic blood pressure ≥ 90 mmHg) with evidence of right ventricular strain by echocardiography or CT with or without evidence of myocardial injury by raised cardiac biomarkers.2Methods: A literature search was conducted using PubMed, OvidSP Platform, Google Scholar, BestBETs, The Cochrane Library - Databases, American College of Chest Physicians (ACCP), American Heart Association (AHA), European Society of Cardiology (ESC), American College of Emergency Physicians (ACEP), and NICE guidelines from 1946 to the 21st March 2018. References of retrieved articles were reviewed for other possibly related citations. The randomized controlled trials (RCTs) were studied and appraised using the Cochrane risk-of-bias tool (Table 1). Results: From 66 potentially relevant studies, six RCTs were published between 2002 and 2017 and included in this systematic review (Table 2). A total of 1568 patients were enrolled: 747 received thrombolytic therapy with alteplase (two trials, 155 patients) or tenecteplase (four trials, 592 patients), and 821 were treated with heparin only. None of these RCTs proved that adding thrombolytic therapy to standard anticoagulant treatment statistically decreased early mortality. The five studies looking at clinical deterioration proved that thrombolysis was beneficial. Five out of six RCTs resulted in a non-significant difference in major bleeding prevalence. Only the PEITHO3 trial proved the opposite. The incidence of minor bleeding was significantly higher in the four studies in which it was measured (Table 3). Conclusions: Currently, there is inadequate evidence to support the use of systematic thrombolysis for patients with acute intermediate-risk PE. Although it may prevent clinical deterioration which necessitates escalation of treatment in the short term, it comes with increased risk of bleeding. Individual risk-benefit patient assessment and shared decision making may be wise until better evidence to proceed otherwise is demonstrated. Larger clinical trials concerning reduced thrombolytic doses and prolonged infusion rate is essential.
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Virtual bronchoscopy and 3D reconstruction in the critical care setting
Authors: Nabil Shallik, Ahmed Labib, Adel Ganaw, Nissar Shaikh, Abbas Moustafa and Yasser HammadBackground: Airway management of the critically ill patient is challenging. An audit of airway management in the UK reported higher incidence of significant airway complications (death and hypoxic brain damage) in the Intensive Care Unit (ICU) compared to regular anesthetic practice in the operating theatre.1 Virtual bronchoscopy (VB) can be valuable in airway management in the ICU. Methods: Virtual reality (VR) emerged in the clinical field 20 years ago2,3 utilizing graphics, high-end information technology, advanced sensors, and human-computer interfaces to create an immersive and interactive artificial environment. Conversion of standard radiological Computer Tomography (CT) images as computer-generated simulation of airway anatomy is referred to as VB or virtual endoscopy (VE).2,3
VB allows the display of high-resolution airway images down to 6/7th bronchial subdivisions and simulates findings of traditional fiberoptic bronchoscopy (FOB)3 (Figures 1 and 2).
The indications of VB in ICU include evaluation and management of tracheobronchial stenosis, airway trauma, inhalation injury, foreign body aspiration, tracheostomy tracheoesophageal fistula (TOF) (Figure 3), and bronchopleural fistula (BPF)2. Results: VB has several advantages including non-invasiveness, non interruption of mechanical ventilation or potential loss of airway, and no need for specific patient preparation. In addition, there is no exposure to contrast and it can be accomplished within a minute. VB allows airway evaluation of intra- and extra-luminal airway structure from all angles in isolation from its surroundings. Being operator-independent is a major advantage of VB.4
FOB has significant limitations and potential complications. These include limited access via severe stenosis, inability to evaluate caliber and morphology of post-stenotic airway, limited information about airway surrounding structures in addition to risk of hypoxia, hypercarbia, and de-recruitment. Notably there is absence of bronchial colour or texture information, no endobronchial gesture such as bacterial sampling is possible, there are many false negatives and false positives, and the reproducibility of the measurements is still mediocre. Adequate sedation is needed during FOB with associated hazards. Moreover, risks of airway trauma, bleeding, pneumothorax, infection, and increased airway pressure with FOB have been observed.2–4
In tracheobronchial stenosis, VB showed sensitivity of 63–100% and specificity of 61–99%, allows examination of the post-stenotic section of tracheobronchial tree and provides information about extra-luminal pathology.3 VB is safe and well-tolerated by critically ill patients and does not pose a risk of contamination or infection of critically ill immunocompromised patients.3
3D reconstruction and VB can be performed either by the radiologist, anesthetist or surgeon on an appropriate workstation utilizing widely available software to generate an internal simulated view of the airway or the pathology. This can be utilized to formulate an airway management plan in critical and challenging situations.4,5
However, retained mucus or blood mimic tracheobronchial stenosis. VB cannot be utilized for evaluation of pulmonary mucosa, biopsy, or pulmonary lavage. Dynamic changes, such as vocal cord palsy can be challenging to appreciate using VB. In addition, VB mandates transfer of critically ill patients to the radiology department and exposure to radiation.3Conclusion: 3D and VB volume rendering of CT images of the airway can provide anesthetists and intensivists with an alternative view of the airway in ICU settings. This can be utilized to formulate an airway management plan in the most demanding conditions.
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Puerperal sepsis and multiple organ dysfunctions caused by group A streptococcus
Authors: Mohammed A. Imran, Nissar Shaikh, Arshad Chanda, Gamal Abdul Rahman and Firdous UmmunnisaBackground: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.1 Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades, although rare, it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region,2 but it caused NEF in only one postpartum patient which is a rarity.3,4,5 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS, and had a fairly positive outcome.
Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever, tachycardia, tachypnea, borderline blood pressure, vaginal discharge, and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg, which was edematous, warm, and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 103/μL), thrombocytopenia (44 × 103/μL), C-Reactive protein was elevated (322 mg/L), and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin), supplemented with oxygen, and resuscitated with intravenous fluids.
She was immediately taken for emergency surgical intervention, right leg debridement, and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures, and clindamycin was started. Intraoperatively the patient became unstable, requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement, she underwent above right knee amputation, lateral and medial thigh compartment fasciotomy, and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12, awake, hemodynamically stable, tolerated oral feeding, and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics.
Conclusion: Despite developments in infection control and strict aseptic precautions, GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis, aggressive surgical management, and supportive medical care are important for a positive outcome.
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Prehospital analgesia for femur fractures: An improvement study
Background: Management of pain in the prehospital setting is an important priority for prehospital clinicians, yet is often underestimated, either due to poor pain assessment, under dosing and inadequate provision of analgesia1,2. A femur fracture is considered a painful injury and as such, should be managed with effective analgesia. Pain is associated with multiple negative physiological effects which may potentially worsen a patient's clinical condition1, further highlighting the importance of providing effective analgesia. Vassiliadis et al., highlighted that patients with a femur fracture receive only moderate analgesia in the prehospital setting and this requires a focused strategy to improve the care received by these patients3. A retrospective audit of the Hamad Medical Corporation Ambulance Service (HMCAS) electronic patient care records (ePCR) highlighted the low frequency of prehospital analgesia for the management of femur fractures (October 2016 – December 2016). The provision of three pharmacological agents (Methoxyflurane, Fentanyl and Ketamine) which are the primary analgesics used by the HMCAS for the management of pain associated with femur fractures was reviewed. These drugs are often used together in a multimodal strategy to manage pain effectively. A multimodal approach to managing trauma pain has the benefit of improving efficacy with multiple mechanisms of action, limiting the number of doses required of a single drug, as well as reducing the risk of side effects4. The aim of this study was to improve prehospital analgesia for femur fractures, by means of introducing a purpose-designed trauma CPD training course. Focused training through the means of high fidelity simulations and simple skills training leads to improved performance and an increase in knowledge gained by the practitioner5, resulting in improved and safer care delivered to patients. Methods: An intervention consisting of a theoretical, individual skills and simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a three-month period (January 2017 – March 2017). The eight-hour trauma CPD training session focused on managing major trauma with specific focus on femur fracture identification and optimization of analgesia (Figure 1). Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the frequency of prehospital analgesia for patients with femur fractures (April 2017 – June 2017). Results: The mean provision of prehospital analgesia for a femur fracture in the pre-intervention stage was found to be suboptimal (Methoxyflurane 61%; Fentanyl 21%; Ketamine 12%). Whereas, following the intervention period, the mean provision of prehospital analgesia for femur fractures increased significantly (Methoxyflurane 100%; Fentanyl 30%; Ketamine 52%). See Figure 2. Conclusion: This study found that focused trauma training is an effective means to improve prehospital analgesia for femur fractures as well as overall patient care. Introduction of the trauma CPD training session resulted in an improvement in the management of pain associated with a femur fracture. Significant room for improvement still exists and prehospital analgesia should continue to be developed. Further research is still required.
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Journal club as a tool to facilitate evidence based practice in critical care
Authors: Emad Almomani, Tawfiq Alraoush, Omar Sadah, Ahmed Al Nsour, Megha Kamble, Jisha Samuel, Karim Atallah, Kobra Zarie and Emad MustafaBackground: A journal club is a forum to debate and review clinical practice using a number of models to gauge the strength of evidence associated with the clinical practice. A large body of evidence supports the importance of journal clubs as a method to improve patient outcome by enhancing the implementation of evidence-based practice and professional development in the clinical setting1–3. Journal club activities have been recommended by the Hamad Medical Corporation (HMC) Critical Care Nursing Network (CCNN), Qatar, and started in the critical care areas of Hamad General Hospital for different critical care specialties such as trauma, surgical, and medical ICUs since 2014. Methods: The journal club is a 1-hour monthly critical care educational activity for HMC critical care nurses. A flyer promoting the article to be discussed is shared with the critical care nurses one week prior to the scheduled date and each session is attended by 15–20 nurses. Participants gain continuing professional development (CPD) credits for each session they attend. The articles discussed cover patient safety and critical care clinical practices. A structured review of the selected articles is facilitated by an expert educator with a research background. The strength of the evidence to change current clinical practice will be evaluated in a group discussion format (Table 1). At the end of each journal club activity, the facilitator summarizes the learning points, recommendations, and the action plan if the group believes changes to current clinical practice are recommended3. Results: Around 50 journal clubs have been conducted in the critical care units of HMC with a total attendance of 1100 nurses. The journal club activity encouraged critical care nurses to establish the first nursing clinical research team in critical care areas of HMC (Table 2). Additionally, it had a positive impact on improving the professional development and competency level of the critical care nurses which were assessed and evaluated by HMC critical care competency assessors through applying the specialty critical care competency checklist. Finally, implementation of the journal club activity and reviewing best available evidence and research literature led to improvements in clinical practice (Table 3). Conclusion: Implementation of the journal club activity helped in developing critical care nurses’ awareness on current research studies and best available evidence, in addition to keeping them up-to-date with new findings, practices, and critical care trends. The journal club with its structured review questions has proven to be an effective way of evaluating the strengths of the evidence presented in the reviewed articles and sometimes led to changing our critical care clinical practice. It also contributes to improving nurses’ ability to critically appraise research articles. Furthermore, it promotes the implementation of new knowledge gained in clinical practice which is expected to improve patient safety and outcomes.
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Prevalence of methicillin-resistant Staphylococcus aureus (MRSA) and use of tunneled hemodialysis catheters
Authors: Akbar Mahmood, Maysa Ahmed Ali Almasrouri and Ali HussainBackground: Hemodialysis patients are at higher risk of contracting infections particularly methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a serious infection and could be fatal within hours to days if undiagnosed. Dialysis catheter commonly known as permacath is a tunnel catheter used for maintenance hemodialysis which is associated with serious complications, especially infections and thrombosis. Different methodologies were designed and tested to determine the relation of infection with permcath. The use of a cuff was thought to prevent catheter related infections but none proved beneficial.1 This finding was supported further in a systematic review conducted in 2009.2 Usage of permacath is on the rise despite awareness of its higher risk of morbidities and mortalities which is contrary to the slogan of Fistula First Initiative.3 We aimed to evaluate the prevalence of MRSA infections in hemodialysis patients with tunneled hemodialysis catheters. Methods: This is a retrospective, qualitative cross-sectional and non-experimental single center study conducted at Sultan Qaboos University Hospital (SQUH) Hemodialysis Unit over eight years. Inclusion criteria include: Adult patients >18 years of age with diagnosis of end stage renal disease requiring hemodialysis. Exclusion criteria included age < 18 years old and patients on peritoneal dialysis. Records of hemodialysis patients from 1st January 2010 through 6th May 2018 were retrieved through TrackCare (electronic medical records). The patients were divided into two groups. Positive MRSA infection (defined as a positive Gram stain with cocci in clusters and which was further confirmed by positive DNA polymerase chain reaction (PCR) for MRSA) either from the periphery or central line or pus swab from the catheter tunnel site at the time of admission or during hospitalization.4 The remaining screened patients were classified as negative MRSA. Informed consent was waived as it is a retrospective study and our work was based on collecting information from TrackCare. All patients’ data were de-identified prior to analysis. Results: From 2010 to 2018, 1356 hemodialysis patients were identified within the hospital information system (HIS). Based on our inclusion criteria, a total of 1064 screened patients were included in our study. Those remaining who were not screened were been excluded. Fifteen patients were detected positive with MRSA infection (Figure 1), 12 patients had permacath and three had arteriovenous fistula (AVF). Overall, the prevalence of MRSA infection was 1.1% (12/1064) in hemodialysis patients with tunneled catheters. Conclusions: In our study, the MRSA prevalence rate was lower than the international reported statistics (4.2–6.5 per 100 patients).5 This supports the use of adequate infection control policies and practices adopted in the unit. We propose that fistula should be the preferred access option for the maintenance hemodialysis. However, in cases where catheter is the only option, due to whatever reason, then using chlorhexidine impregnated dressings in addition to standard catheter care techniques result in reduced infection incidence. Furthermore, use of topical antibiotics at catheter exit sites can reduce the risk of infection.
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Extracorporeal cardiopulmonary resuscitation for aortic rupture secondary to purulent pericarditis
Authors: Khaled El Shafey, Bilal Zuby, Walid Jbawi, Baha Juma, Tejas Mehta, Jamil Zen Alabidin and Imran IbrahimBackground: Extracorporeal Cardiopulmonary Resuscitation (ECPR) has been increasingly usedfor failed conventional CPR. Successful use in sudden major vessel rupture hasn't been reported. Cases of community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) pericarditis associated with major vessel rupture however are limited in number1 with a reported mortality of 20–30%.2 Here we present a case of CA-MRSA pericarditis that was complicated by aortic rupture in which ECPR was successfully utilized. Methods: A four-year-old boy presented with fever, abdominal pain and vomiting for one day. He had a fall from a tricycle with potential abdominal injury the day before and had a small gluteal abscess present for four days. Examination showed slight tachycardia, mild tachypnea and low-grade fever. CBC showed neutrophilic leukocytosis. Initial chest x-ray, electrocardiogram, and abdominal tomography scan were normal. He was managed with analgesics and covered with ceftriaxone. Chest CT done on the third day due to tachypneashowed pericardial and bilateral pleural effusions. Echocardiography showed a large pericardial effusion with a collapsing atrium, indicating tamponade. Emergency pericardiocentesis retrieved 120 ml of serosanguinous fluid. A pigtail catheter was left in-situ. Intravenous vancomycin was added to the antibiotic coverage. Pericardial fluid culture grew MRSA. He showed clinical improvement, and inflammatory markers showed progressive decrease. Pericardial drain was removed after five days as the drained fluid became minimal. Subsequent echocardiograms showed only debris in the pericardial space.
Five days later while looking well, he coughed, desaturated, and became hemodynamically unstable. He was resuscitated for 55 minutes, during which he mostly had pulseless electrical activity. Bedside sternotomy was done during resuscitation to initiate central ECMO as part of ECPR. The pericardial sac was bulging, and when opened, around 500 ml of fresh blood with clots came out. Blood jets were coming from the ascending aorta which was found ruptured and covered with a thick layer of organized pus. Pus was removed from around the superior vena cava, right ventricle and ascending aorta, and the aorta was sutured.The patient was connected to femoral VA ECMO as the aortic wall was very friable. Results/outcome: The patient was decannulated from ECMO after 3 days and discharged from hospital after 2 months. At discharge, he was alert, communicating and had generalized weakness. MRI brain showed hypoxic ischemic changes. Conclusion: This is the first pericarditis case reported to develop aortic rupture, and the first to survive after a pericarditis-associated major vessel rupture, with utilization of ECPR and timely surgical repair. One case ofMRSA purulent pericarditiswith pulmonary trunk rupture was reported in a 68 year old woman who expired due to massive bleeding and difficulty of surgical repair.3 Although pericardiectomy should be considered from the outset in the management of purulent pericarditis,4 surgical intervention was not considered initially as the aspirated pericardial fluid was visually serosanguinous andsubsequent echocardiograms didn't show reaccumulation. Prior to admission, there was a small gluteal abscess, which probably served as the portal of entry for the MRSA but was dry at the time of admission and was not sampled.
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Abdominal necrotizing fasciitis causing acute myocardial infarction
Authors: Arshad Chanda, Nissar Shaikh, Arif Viallani, Narjis Mumtaz, Adel Ganaw and Shakeel RiazNecrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high mortality rate.1,2 NF is a severe form of soft-tissue infection. When NF is complicated with acute myocardial infarction (AMI), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI), the patient's chance of survival are diminished significantly.3,4 We present a case of NF of the abdominal wall with acute non-ST segment elevated myocardial infarction (NSTEMI). No such case has previously been reported according to our review of the literature. Case: A 52-year-old female with a known case of hypothyroidism presented to the emergency department with severe abdominal pain for two days. She gave the history of abdominal hernia repair ten days back. She had sinus tachycardia but other vitals were normal, with no fever or leucocytosis. Computed Tomography (CT) of the abdomen showed anterior abdominal wall collections. Septic workup was done, cefuroxime and metronidazole were started. Her abdominal wall collection was drained under image guidance. After a few hours, her blood pressure dropped and was not responding to fluid challenges so a noradrenaline infusion was started and she was transferred to the surgical intensive care unit (SICU). Her blood work showed lactic acidosis. Her abdomen was tender all over with swelling and induration of the abdominal wall. Antibiotics were changed to meropenem and clindamycin to broaden the spectrum in view of the septic shock and she was immediately taken for exploratory laparotomy. The operative findings were suggestive of necrotizing fasciitis of the anterior abdominal wall and a bold and thorough debridement was done. She was kept intubated and ventilated for a second look and further debridement was conducted after 24 hours.
Six-hours post-surgical debridement, electrocardiographic (ECG) changes were noticed, 12-lead ECG showed ST-segment depression in leads II, III, aVF, and V5-6, with raised cardiac biomarkers and lower cardiac index (Figures 1 & 2), diagnosed as NSTEMI. Heparin infusion, aspirin, and clopidogrel were started. Echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction: 45%) with septal dyskinesia. Dobutamine infusion (guided by the PiCCO study) was started, which improved her hemodynamic parameters. CT coronary angiography was inconclusive. These findings suggested that she suffered Type II myocardial infarction due to the stress. She developed oliguria which improved with the restoration of hemodynamics. Her lung condition also deteriorated (PaO2/FiO2 ratio dropped to 100), requiring maximum ventilatory support and she was managed as per ARDS guidelines.5 Blood culture showed growth of Group F Streptococci and Prevotella melaninogenica. Meropenem was continued as the growths were sensitive to it.
By day six, she started to be weaned off from the ventilator and vasopressors. She was extubated on day nine and transferred to the ward on day ten. She was later discharged home to be followed up in the surgical outpatient clinic. Her length of stay was 15 days. On a six-month follow-up, she was functionally independent, on aspirin, clopidogrel, and thyroxin therapy. Conclusion: Our patient had NF of the anterior abdominal wall leading to septic shock and complicated by NSTEMI, ARDS, and AKI. Timely source control, close monitoring, quick, and effective interventions appear to have resulted in her excellent recovery.
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