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

Chest radiographs in acute pulmonary embolism

Pulmonary embolism [PE] is a serious clinical entity carrying significant morbidity and mortality. Clinically, it is a difficult condition to diagnose and remains under treated condition in Pakistan due to non-availability of objective tests and lack of awareness among physicians. This study was conducted to determine the chest radiographic presentation in known cases of acute PE presenting to a tertiary care hospital. hospital records of patients with a diagnosis of acute PE were reviewed from June 2000 until June 2004. fifty diagnosed cases of defect were selected. Two chest physicians reviewed the chest demonstrating an intraluminal-filling hospitalization. In case of discrepancy, a radiologist made final interpretation. The chest radiograph was interpreted as normal in only 18% of patients with acute PE. The most common chest radiographic abnormalities were cardiac enlargement [38%], pulmonary parenchymal infiltrates [34%], atelectasis [26%], pleural effusion [24%], and pulmonary congestion [24%]. Other rare findings were elevated hemi diaphragm [14%], pulmonary artery enlargement [14%], and focal oligemia [8%]. Cardiomegaly is the most common chest radiographic abnormality associated with acute pulmonary embolism. Its major role is in identification of alternative disease processes that can mimic thrombo-embolism

Outcome of home mechanical ventilation

To determine the outcome of patients discharged home on portable ventilator. The Aga Khan University Hospital, Karachi from January 2000 to December 2004. All ventilator-dependent patients discharged home were contacted. Survivors were administered the EQ-5D Quality-of-Life instrument. SPSS version 13 was used to analyze data. Eleven patients were discharged home on invasive ventilation. Mean age was 49 years [range10-98 years]. Cause of ventilatory failure were cervical spine trauma in 36%, primary neurological disease in 27%, critical illness neuropathy and respiratory failure in 18% each. Survival rate was 73%, with three deaths. Mean duration of ventilation was 9.45 months [95% CI 3.24, 15.67]. Rate of successful weaning after discharge was 36%, with 4 patients off all forms of ventilatory support and 2 on only nocturnal support. A 2.8 [95% CI 0.5, 16.6] relative risk towards successful weaning was associated with the presence of a family member as the primary care giver. Mean scores on the EQ-5D descriptive tool were; mobility 2 [ +/- 0.82], self-care 2 [ +/- 0.82], usual activities 1.86 [ +/- 0.69], pain/discomfort 1.43[ +/- 0.79], anxiety/depression 1.29 [ +/- 0.76]. Mean score on the EQ-VAS was 48.2[ +/- 27.3]. In carefully selected patients, home ventilation is a viable option with the expectation of successful weaning and survival. Patients discharged home on ventilation reported a reasonably good quality of life with proportionately more problems related to independence compared to overall well-being