Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Neonatal resuscitation; the use of laryngeal mask airway

The key to success in newborn resuscitation is the knowledge about the neonatal physiology and adequate preparation of the staff involved in the resuscitation process. The pulmonary part of the resuscitation can be accomplished with either Endotracheal Tube [ETT] or Face Mask [FM], both of these techniques require expertise and are associated with high rates of failure. Hence a third potential option has been suggested to overcome these problems. To evaluate the efficacy of Laryngeal Mask Airway [LMA] in neonatal resuscitation and artificial ventilation and to compare it with that of ETT and FM. To evaluate LMA's efficiency in situation where endotracheal intubation and facemask ventilation is difficult or not possible. A Non interventional, analytical/ comparative study. Combined Military Hospital Rawalpindi. 20 weeks [1st] January 2002 to 31 May 2002]. A group of 75 neonates born with C-Section were selected on the basis of non-probability convenience sampling. They were subdivided into three sub gps with 25 neonates in each sub gp. 75 neonates born after C-Section, were divided into sub gps i.e. A, B, and C containing a no of 25 neonates in each gp. They were ventilated with ETT, FM and LMA respectively. These newborn babies had an Apgar score < 4. They were resuscitated using a fix protocol. The efficacy of ventilation with either technique was evaluated in terms of placement and ventilation. The LMA emerged, as a valuable and better option in newborn resuscitation. Moreover, it was a successful tool in situations where endotracheal intubation and facemask ventilation was difficult or impossible. The LMA is a potential valuable adjunct for the management of neonatal airway