Critically ill obstetric patients requiring mechanical ventilation in rural western India: A retrospective analysis.

Background. There is a dearth of studies on the clinical profile and therapeutic aspects of critically ill obstetric patients from rural areas, especially those requiring tertiary care support and ventilator therapy. Methods. We retrospectively analysed the aetiological, clinical, interventional and outcome-related factors of obstetric patients requiring mechanical ventilation in western India. We analysed factors that influence seeking of antenatal care, pregnancy and its complications, severity assessment score, indications and initiation of mechanical ventilation, multiorgan failure and their correlation with maternal mortality. Results. Of the 6708 obstetric admissions studied, 1112 were of critically ill (16.5%) patients and 200 (17%) of these required mechanical ventilation. Over three-fourths (77%) of patients were from rural areas, 83.5% were referred and 97% had inadequate antenatal care. Severe pregnancy-induced hypertension/eclampsia, massive haemorrhage and sepsis were the common obstetric complications. Pulmonary oedema (32.5%), acute respiratory distress syndrome (ARDS, 14%) and acute lung injury (22.5%) were the three most common indications for mechanical ventilation. In 26% of patients, mechanical ventilation was initiated early based on a worsening cardiorespiratory profile. A sequential organ failure assessment score of >5 on admission and delay in treatment resulted in multi-organ failure and worsening outcome. The maternal mortality ratio was 32.5%, incidence of multi-organ dysfunction syndrome was 71%, and pregnancy loss was 43.5%. The odds ratio for maternal mortality in patients ventilated early was 0.39 as against 5 in those with ARDS. Conclusions. Inadequate antenatal care, delayed referral practices, pregnancy-induced hypertension, obstetric haemorrhage and sepsis remain the major causes of complications in obstetric patients from rural areas. The common indications for mechanical ventilation were pulmonary oedema, ARDS and acute lung injury. Early initiation of mechanical ventilation upon detection of imminent

Educational intervention to improve death certification at a teaching hospital.

Background. Information recorded in the ‘cause of death’ section of death certificates is an important source of mortality statistics. It is used for policy decisions, development of healthcare programmes and health research. Errors in death certificates can lead to inappropriate allocation of resources. Errors are universal and have been reported previously. We planned an educational intervention aimed at resident doctors from various specialties at our teaching hospital to improve the accuracy of the ‘cause of death’ section in death certificates. Methods. Three workshops, each of 90 minutes, were conducted for residents. A total of 198 death certificates (96 before and 102 after intervention) were audited. We compared the frequency of major and minor errors before and after the educational intervention. Results. Following the educational intervention, there was a significant decrease in major errors such as unacceptable underlying cause of death (39.6% v. 24.5%, p=0.034), reporting of mechanism without underlying cause of death (13.5% v. 1%, p=0.001) and improper sequencing of events (25% v. 6%, p=0.004). There was no significant decrease in minor errors such as absence of time intervals, use of abbreviations and reporting a mechanism with a legitimate cause. Conclusion. Both major and minor errors are common in death certification at teaching hospitals. Educational interventions can improve the accuracy of reporting in death certificates.

Bronchobiliary fistula: an anaesthetic point of view.

Bronchobiliary fistula is defined as the passage of bile in the bronchi and in the sputum (bilioptysis). This rare disorder is associated with significant morbidity. Authors review the anaesthetic management of bronchobiliary fistula and recommend the use of double lumen endotracheal tube even in cases with a closed/sealed bronchobiliary fistula.