Cumulative fluid balance as a major predictor of clinical outcome in patients admitted to surgical intensive care unit

Objective: Fluid balance remains a highly controversial topic in the critical care field, and there is no consensus about the amount of fluid required by critically ill patients. In this study, the objective was to find the relationship between fluid balance and in hospital mortality in critically ill surgical patients. Our secondary objective was to identify the association between use of colloid and acute kidney injury and use of blood products and development of ARDS

Study Design: The medical records of adult patients admitted to a surgical intensive care unit [ICU] >48 hours, from Aug 2014 to Feb 2016 [18 months] were reviewed retrospectively

Place and Duration of Study: The study was conducted in the surgical intensive care unit of a tertiary care hospital. Medical records of 18 months from Aug 2014 to Feb 2016 were reviewed

Material and Methods: Sampling technique was convenience sampling. A total of 100 patients met the inclusion criteria. Abstracted data of patients admitted to surgical intensive care included body mass index, Acute physiology and chronic health evaluation [APACHE]-II scores, fluid balance during first 5 days of ICU stay, length of ICU stay and in hospital mortality. All statistical analysis was performed using statistical packages for social science version 19 [SPSS Inc., Chicago, IL]. Frequency and percentage were computed for qualitative observation and were analyze by chi-square test. Mean [+/-Standard deviation] and median [IQR] were presented for quantitative variables and analyze by independent sample t-test and Mann-Whitney test. Normality of quantitative data was also be checked by Kolmogorov-Smirnov test. Statistically significant results had a p-value less than 0.05

Results: A total of 100 patients fulfilled the inclusion criteria. The average age of patients was 44.08 +/- 18.14 [years], BMI [kg/m2] 27.84 +/- 5.56 and APACHE II Score 17.28 +/- 6.96. The in hospital mortality was 26 percent, median length of ICU and hospital stay was 6.91 +/- 4.07 and 14.74 +/- 7.78 days. In non-survivors fluid balance was significantly positive on 2nd, 3rd, 4th and 5th day of SICU [p-value: 0.005, 0.0005 and 0.024], APACHE II score [p<0.02], incidence of acute kidney injury [p<0.004] and mechanical ventilation days were significantly more. There was association between the use of colloid and acute kidney injury [p<0.014]. Use of blood products was significantly associated [p<0.03] with development of ARDS

Conclusion: Positive fluid balance, high APACHE II score and acute kidney injury is significantly associated with hospital mortality of non-cardiac surgical ICU patients

Anesthetic management for open heart surgery and extracorporeal circulation

Cardiopulmonary bypass [CPB] required for cardiac surgery presents unique challenges to the cardiac anesthesiologist who is responsible not only for maintaining hemodynamics but at the same time anesthesia and analgesia for these patients. Unique pathophysiologic changes during CPB result in pharmacokinetic alterations that impact the serum and tissue concentrations of IV and volatile anesthetics. CPB has evolved into routine, safe and reliable system that requires intensive specialized training to operate. It is the function of the perfusionist to maintain and operate this equipment during CPB; however anesthesiologist and surgeon caring for the patient undergoing CPB bear the responsibility of understanding this equipment and its function in order to manage the patient undergoing surgical procedure safely. Anesthetic management of patient coming for cardiac surgery and different component of cardiopulmonary bypass will be discuss in this review article

World sepsis day in Pakistan

Celebration of World Sepsis Day at a global level started just three years back, and the immense importance of this celebration was not lost to Pakistan Society of Anaesthesiologists [PSA] and Pakistan Society of Critical Care Medicine [PSCCM]. Both these organizations were quick to grasp the opportunity to use it to achieve the common goal of enhancing the level of awareness about sepsis and prevention of sepsis among the healthcare professionals as well as higher authorities. The result was multiple international academic events being organized regularly across the country as well as the adoption of National Sepsis Guidelines. The struggle to create more awareness about sepsis continues

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

APACHE II analysis of a surgical intensive care unit population in a tertiary care hospital in Karachi [Pakistan]

Performance of prognostic models deteriorates over time by changes in case-mix and clinical practice. This study was conducted to describe the case-mix of a surgical intensive care unit [SICU] and assess the performance of APACHE II scoring system in this cohort. We analyzed 213 adult patients admitted to the surgical intensive care unit [SICU] of Aga Khan University Hospital, from January 2011 to December 2012 and the performance of APACHE II scoring system was assessed in this population. The mean age of patients was 46.31 years [SD +/- 18.43], 67.1% patients were male and mean length of ICU stay was 6.54 days [SD +/- 7.18]. Admissions to SICU were from seven service departments with the highest admissions from general surgery followed by trauma and neurosurgery. The mean APACHE II score of this SICU population was 15.89 [SD +/- 8.06], 12.88 [SD +/- 6.29] in survivors and 22.24 [SD +/- 7.66] in non-survivors [p <0.01]. The overall mortality was 33%, with SMR of 1.0. No patient survived with an APACHE II score of more than 34. In this SICU population the calibration and discrimination of the APACHE II scoring system was acceptable, i.e. [[H-LS 11.76 [p=0.l6]] and [area under the receiver operating curve = 0.83]. APACHE II scoring system allows meaningful analysis of SICU population, therefore, it is recommend, that this simple and cost effective scoring system should be used to identify patients with high risk of death to justify the decisions of withholding expensive therapies in resource limited settings

review of critical care management of maternal sepsis

Sepsis is a leading cause of preventable maternal mortality in developing countries due to poverty, home deliveries by untrained persons in unhygienic conditions, limited access to healthcare facilities and lack of availability of antibiotics. Recent confidential enquiries into maternal deaths from the developed nations have revealed an increase in maternal mortality secondary to genital tract sepsis and provision of suboptimal critical care. Early recognition of critical illness in obstetric patients, involvement of intensive care teams earlier and provision of same standard of critical care to pregnant women as non-pregnant patients while being mindful of the altered maternal physiology and fetal wellbeing is necessary to improve outcome of this vulnerable population.This article reviews the definitions and risk factors of maternal sepsis and describes the standards recommended for efficient delivery of maternal critical care and sepsis management

Rare presentation of posterior reversible encephalopathy syndrome [PRES] and neurogenic stunned myocardium in a patient after emergency cesarean section

Posterior Reversible Encephalopathy Syndrome [PRES] is clinically characterized by seizures, lethargy, nausea and visual impairment. These findings are thought to be due to vasogenic edema, predominantly in the posterior cerebral hemispheres and are reversible with appropriate management. Neurogenic-stunned myocardium is a syndrome of reversible left ventricular dysfunction, associated with excessive sympathetic discharge states like pheochromocytoma, high-grade subarachnoid hemorrhage [SAH], status epilepticus and significant emotional stress. Here, we report a case of PRES and Neurogenic-stunned myocardium occurring simultaneously in a 25 year old primigravida at 34 weeks of gestation with twin pregnancy who presented to the emergency department with eclampsia and fetal distress. A careful review of literature did not return any report where these two conditions co-existed in an obstetric patient

Local infilteration of steroid in conjunction with coccygel manipulation as a treatment of coccydynia

To asses the efficacy of local infiltration of steroid in conjunction with coccygel manipulation as a treatment of coccydynia. Interventional study. Department of Orthopaedic Surgery, Ziauddin Hospital Karachi, from December 2000 to December 2008. All selected patients who did not improve three to six month of conservative treatment, were enrolled. The patients were treated with local infiltration of steroid in conjuncation with coccygel manipulation and followed for up to 2 years. A total of 172 patients were diagnosed with coccydynia. The average age of the patients was 38.3 year. There were 138 [80.2%] males and 34 [19.8%] females. Trauma was responsible for pain in 118 [68.6%] cases. Of the total patients, 97 [56.4%] recovered with conservative management and remaining 75 [43.6%] underwent manipulation of coccyx under sedation with local infiltration of steroid. Fifty three [70.7%] patients had excellent results, 14[18.7%] had good response and 8 [10.7%] had fair outcome on first visit. In 2 year follow up 60 [80%] patients showed good response. Second injection was given in 5[6.7%] patients and 3[rd] injection was needed in one [1.3%] patient. Nine [12%] patients were lost to follow up. We recommend manipulation along with local infiltration of steroid in all patients of coccydynia. This approach is less invasive and carried out under sedation as a daycare procedure.

Malpractices of hand hygiene in nursing staff: a global threat for increasing incidence of infections

This study assessed the knowledge, practice of standard hand hygiene in nursing staff to identify the causes of not adapting hand hygiene techniques during routine patient care. A cross sectional study. This study was carried out in Karachi in various public sector hospitals i.e. Jinnah Postgraduate and Medical Centre, National Institute of Child Health, Civil Hospital Karachi, Sindh Institute of Urology Transplantation, National Institute of Cardiovascular Diseases. The study completed in six months from May to November 2010. A sample of 335 nursing staff was selected, convenient sampling was used, consent was taken. They were asked about their practices of hand hygiene through structured questionnaire at five major public sector hospitals of Karachi, Pakistan. Out of 335 nursing personnel. 71.9% were unaware that washing hands under running water for 30sec to 1min remove most of the germs. 74.62% knows that hand washing is necessary. Regarding practices, 35.5% use sanitizers while 47.2% use antiseptic, normal soap for washing hands. 67.1% practice hand washing before and after coming in contact with patients. 43.7% took some treatment after needle prick while others [56.3%] didn't feel the necessity to take any treatment, regardless of the risk of Hepatitis, IHV. 36.1% adopted sterile techniques after hand washing. Surveillance was below average [46.6%]. Hand hygiene knowledge, practices of nursing staff is part and parcel for minimizing infections. Adequate hand washing facilities, positive attitude towards hand hygiene, adherence to practice, strict surveillance system for hand hygiene is essential to combat increasing incidence of infections