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

Nosocomial tracheobronchitis in mechanically ventilated patients: frequency, aetiology and outcomes

The aim of this study was to determine the frequency, etiology, microbiological sensitivity and outcomes of nosocomial tracheobronchitis [NTB] in mechanically ventilated patients admitted in surgical intensive care unit. A prospective observational study was conducted in the Surgical Intensive Care Unit [ICU], Department of Anaesthesiology, Civil Hospital Karachi from April 2009 to April 2010. All the patients on mechanical ventilator for more than 48 hours in the ICU were evaluated according to the criteria for the diagnosis of nosocomial tracheobronchitis [NTB]. Outcomes of the patients were measured in terms of development of nosocomial pneumonia after NTB, length of ICU stay, duration of mechanical ventilation and mortality in the ICU. Two hundred and eighteen patients were evaluated for this study. Nosocomial tracheobronchitis was diagnosed in 72 patients. The frequency of NTB was 33%. Sixteen types of organisms were identified, 61.23% cases were poly-microbial, while in the remaining 39.7% cases single organism was isolated. The most common organism was gram negative Acinetobacter spp [51%], followed by Klebsiella spp [29%] and Pseudomonas aeruginosa [16.6%]. Escherichia coli and other gram negative rods were 13.8 % and 11.4%, respectively. There were 4.16 % cases of MRSA isolated in patients who had positive cultures for gram negative organ-isms [poly-microbial]. Ceftriaxone was given in 44% cases as empirical therapy and continued in 33% cases after microbial sensitivity and replaced in 11% cases after culture sensitivity to Cefiperazone + salbactum and in 14% cases cefiperazone was given in combination therapy. Imipenem was used in 28.5% of patients. Quinolones were used in 19% contaminated cases of gut surgeries. Nosocomial tracheobronchitis was significantly associated with increased length of ICU stay and longer duration of mechanical ventilation in our patients when compared to those patients who did not develop NTB [p<0.001]. Moreover, out of 72 patients, 11 developed subsequent nosocomial pneumonia. There was no statistically significant difference noted in mortality rates among patients with NTB and without NTB [43% vs. 41%]. The mortality was related to concomitant comorbitidies, primary cause and surgical outcomes. Nosocomial tracheobronchitis is a common infection in mechanically ventilated patients that significantly affects the development of pneumonia and length of ICU stay for the patients. This study was an insight to the state of NTB in an ICU setup. The higher frequency of NTB demands such studies to set protocols in every intensive care unit

New single use supraglottic airway device with non-inflatable cuff and gastric tube channel

To assess ventilatory characteristics and airway complications associated with the use of I-gel in patients undergoing gynaecological surgeries. Experimental study. Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Civil Hospital, Dow University of Health Sciences, Karachi, from July 2008 to June 2009. One hundred adult female patients aged 15 - 75 years, ASA-I and II scheduled for elective gynaecologic surgical procedures under general anaesthesia with controlled ventilation were included in this study. After insertion of device, ease of insertion, time of insertion, peak airway pressure, leak pressure were noted. After proper placement of device, gastric tube was also passed in every patient. Pharyngolaryngeal morbidities [sore throat, dysphagia, dysphonia, neck pain and coughing at 1 hour and 24 hours postoperatively] were also noted. I-gel was inserted in the first attempt in 92% patients while second attempt was required in 8% of patients. Average time of insertion was 9.68 +/- 2.69 seconds. Average leak pressure of 22.48 +/- 2.07 cm H[2]O. After removal of I-gel no blood staining was found on any device. Coughing was noted in 6% patients after removal of device and mild sore throat was noted in only one patient after 24 hours of surgery. I-gel is a simple and easy to use supraglottic airway device. Its insertion do not require laryngoscopy and airway can be maintained in very short time in adult female patients

Comparison of performance and safety of i-gel with laryngeal mask airway [classic] for general anaesthesia with controlled ventilation

To compare ease of insertion, effectiveness of the positive pressure ventilation and airway complications of i-gel with laryngeal mask airway-classic [LMA] for general anaesthesia with controlled ventilation. This study was conducted in the Department of Anaesthesiology, Surgical intensive care unit and Pain Management, Civil Hospital Karachi, Dow Medical College, Dow University of Health Sciences, from July 2008 to December 2008. One hundred adult patients aged 15 to 75 years, ASA I and II, Mallampati I and II, scheduled for various elective general or orthopaedic surgical procedures under general anaesthesia with controlled ventilation were included in the study. The patients were divided into two groups e.g. i-gel group or LMA group by systematic random sampling technique. Anaesthesia was induced and maintained with a standard gasrelaxant-IPPV technique. Ease of insertion was noted on a 3-grade scale. After insertion of the device vital signs and oxygen saturation were monitored non-invasively. Effectiveness of the positive pressure ventilation was compared. Pharyngolaryngeal morbidity, e.g. sore throat, dysphagia, dysphonia, blood on device, neck pain and cough were noted immediately on removal of the device, and by patient interviews at 1 hour and 24 hours postoperatively. In this study both LMA-classic and i-gel were easy to insert and did not require laryngoscope for insertion. Patients of i-gel group had comparatively less pharyngolaryngeal morbidity [blood on device] than patients of LMA group [18% in LMA group while none in i-gel group]. Both supraglottic devices, LMA [classic] and i-gel can be used safely and effectively in selected patients for general anaesthesia with controlled ventilation with almost no morbidity

Perioperative anesthetic management of a patient with severe von Willebrand disease for major gynecological surgery

Perioperative management of patient with severe von willebrand disease [vWD] especially from major surgery is always a challenging task for the anesthesiologists. Wer report a case of a 17 year old female, diagnosed as a case of vWD at 8 years of age, who was scheduled for exploratory laparotomy for ruptured ovarian cyst with hemoperitonium. She was successfully managed with factor VIII, fresh frozen plasma [FFP] and tranexamic acid administration. Intraoperatively, more than 2 liters of clotted blood was removed and 1.5 liters of fresh blood was lost, which was replaced by red cell concentrate [RCC], colloid and crystalloid solutions. Post-operatively, cryoprecipitates and RCC were transfused. Postoperative serum coagulation studies remained within normal limits. She was transfused with cryoprecipitates and factor VIII till 5 th day. Patients with vWD do not carry an increased operative risk during elective procedures if appropriate prophylactic and corrective therapy is administered. Apart from the administration of cryoprecipitate and other blood products; factor VIII is needed for patients with severe vWD

Recovery profile - a comparison of isoflurane and propofol anesthesia for laparoscopic cholecystectomy

To compare the recovery profile in terms of time of extubation, eye opening, orientation and mobility and frequency of Postoperative Nausea and Vomiting [PONV] between propofol and isoflurane based anesthesia in patients undergoing laparoscopic Cholecystectomy with prophylactic antiemetic. Quasi-experimental study. Department of Anesthesia, Civil Hospital and Dow University of Health Sciences, Karachi, from January to April 2007. After informed consent, a total of 60 ASA I-II patients scheduled for laparoscopic Cholecystectomy were divided in two equal groups I and P. Anesthesia in all patients were induced by Nalbuphine 0.15 mg/kg, Midazolam 0.03 mg/kg, Propofol 1.5 mg/kg and Rocuronium 0.6 mg/kg. Anesthesia was maintained with Isoflurane in group I and propofol infusion in group P, while ventilation was maintained with 50% N[2]O/O[2] mixture in both the groups. All patients were given antiemetic prophylaxis. Hemodynamics were recorded throughout anesthesia and recovery period. At the end of surgery, times of extubation, eye opening, orientation [by modified Aldrete score] and mobility [recovery profile] were assessed. PONV was observed and recorded immediately after extubation, during early postoperative period [0-4 hours] and late period [4-24 hours]. Antiemetic requirements were also recorded for the same periods in both the groups. Propofol provided faster recovery [extubation and eye opening times] and orientation in immediate postoperative period with statistically significant differences between the groups [p<0.0001]. Recovery characteristics were comparably lower in group I. More patients achieved full points [8] on modified Aldrete score at different time until 30 minutes in group P. Postoperative nausea and vomiting in early and late periods were significantly reduced in group P. Moreover, requirement of rescue antiemetic doses were significantly lower in group P in 24 hours [p<0.0001]. In this series, recovery was much faster with earlier gain of orientation with propofol anesthesia compared to isoflurane in the early recovery periods. Propofol is likely to be a better choice of anesthesia because of its better anti-emetic property that persists long into postoperative period and reduces the risk of PONV

Dexamethasone plus Ondansetron for prevention of postoperative nausea and vomiting in patients undergoing Laparoscopic Cholecystectomy: a comparison with Dexamethasone alone

To compare the efficacy of combination of dexamethasone plus ondansetron with dexamethasone alone for postoperative nausea and vomiting in patients undergoing laparoscopic cholecystectomy. Double blinded randomized controlled clinical trial. Department of Anaesthesiology, Surgical Intensive Care Unit and Pain Management, Dow University of Health Sciences and Civil Hospital, Karachi, from March 2007 to September 2007. One hundred patients, both male and female, age 20 to 50 years, ASA Physical status I and II, scheduled for elective laparoscopic cholecystectomy under general anaesthesia were randomly allocated to two groups. Group A received dexamethasone [2 ml] plus ondansetron 4 mg [2 ml] prepared in two different syringes, and group B received dexamethasone 8 mg [2 ml] and normal saline [2 ml], prepared in two separate syringes just before induction of anaesthesia. Anaesthesia was standardized. For the first 24 hours after anaesthesia, the presence or absence of nausea and vomiting [by simply yes or no] was assessed by anaesthetist blinded to randomization. The rescue antiemetic [metoclopromide 10 mg] i.v., was given, if patient remained nauseous for more than 15 minutes, or experience retching or vomiting during study period. In comparison to dexamethasone group, the frequency of nausea and vomiting was clinically and statistically lower in dexamethasone - ondansetron group [p=0.035]. Use of rescue antiemetic was significantly higher in dexamethasone group [p=0.022]. Two patients in group A and one patient in group B experienced peri-anal itching at time of giving dexamethasone, none of our patients experienced headache, flushing or other side effects. Combination of dexamethasone plus ondansetron is more effective in preventing postoperative nausea and vomiting than dexamethasone alone when used for prophylaxis of PONV before the induction of anaesthesia in patients undergoing laparoscopic cholecystectomy

Use of recombinant factor VII for massive posrtpartum haemhorrage: Case serie and review of literature

Recombinant activated factor VII is indicated mainly for the treatment of patients with haemophilia inhibitors. It has also been found successful in the treatment of platelet disorder Glanzmann's thrombasthenia. Recently, its use in trauma patients and in patients with intracereberal haemorrhage has become well established. We present three cases of massive post partum haemorrhage treated with rFVIIa, following caesarean section. The response of these three patients is discussed along with review of literature

Comparison of 25-gauge quincke and whitacre needles for postdural puncture headache in obstetric patients

To compare the frequency of postdural puncture headache [PDPH] and failure rate of spinal anesthesia using 25-gauge Quincke and 25-gauge Whitacre needles in obstetric patients. Single blinded, interventional experimental study. This study was conducted at the Department of Anesthesiology, Pain Management and Surgical Intensive Care Unit, Dow University of Health Sciences and Civil Hospital, Karachi from November 1, 2003 - April 15, 2004. One hundred females, aged 18-35 years, ASA physical status I and II, with singleton pregnancy undergoing elective or emergency cesarean section under spinal anesthesia were randomly allocated to receive spinal anesthesia either by using 25-gauge Quincke or 25-gauge Whitacre needles. Patients were followed for 3 days postoperatively. Headache, its relation with posture, onset, duration, severity and response to the treatment were recorded. Compared with the Whitacre group, frequency of postdural puncture headache was significantly higher in Quincke group [p=0.015], while the overall occurrence of non-postdural puncture headache [NPDPH] did not differ significantly between two groups [p=0.736]. Most of PDPH developed on 2nd postoperative day, were mild in nature and resolved within 48 hours of their onset. There was no significant difference in the failure rate of spinal anesthesia in both groups [p=0.149]. It is suggested that use of 25-gauge Whitacre needle reduces the frequency of PDPH without increasing the failure rate of spinal anesthesia in obstetric patients

Comparison of caudal bupivacaine and bupivacaine-midazolam for peri and postoperative analgesia in children

To compare the duration and side effects of postoperative analgesia of caudal bupivacaine and bupivacaine-midazolam mixture. Design: Single blinded, interventional experimental study. Place and Duration of Study: The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College and Civil Hospital, Karachi from May to November, 2002. Subjects and Sixty children, aged 1-8 years, ASA physical status I and II, undergoing inguinal and urogenital surgery were randomly allocated to receive either 0.25% bupivacaine 0.75 ml/kg [group A] or 0.25% bupivacaine 0.75 ml/kg along with 0.1% midazolam 50mg/kg [group B] by caudal route immediately after induction of general anesthesia. Anesthesia was maintained till the end of surgery. Cardiorespiratory data, sedation and pain score were recorded for 24 hours following recovery from anesthesia. Analgesia was supplemented [diclofenac suppository] whenever the pain score was > or = 4. Duration of analgesia was recorded. The duration of analgesia was 21.41 + 2.7 hours in bupivacaine midazolam group and 9.97 + 2.25 hours in bupivacaine group, which showed a significant difference [p < 0.001]. There was no significant difference in heart rate, respiratory rate, blood pressure and the incidence of side effects in both groups [p = 0.716]. The sedation score were significantly higher in bupivacaine-midazolam group during first hour postoperatively [*p = 0.003]. Addition of midazolam to caudal bupivacaine provides longer duration of postoperative analgesia without having significant side effects but with higher sedation score for 1 hour postoperatively

Single dose dexamethasone as antiemetic following abdominal hysterectomy

The purpose of the study was to evaluate the prophylactic effect of single -dose dexamethasone [8 mg] on postoperative nausea and vomiting [PONV] in women undergoing abdominal hysterectomy. Metoclopramide and saline served as controls. One hundred twenty women [40 in each of the three groups] undergoing abdominal hysterectomy under general anesthesia were enrolled in this randomized, double-blinded, placebo-controlled study. After tracheal intubation, group I received IV dexamethasone 8 mg, whereas groups II and III received IV metoclopramide 10 mg and saline, respectively. Patients in-group I reported a lower incidence of PONV and requested less rescue antiemetics than those in group III during the first four postoperative hours [P <0.01]. Patients in group I reported a lower incidence of PONV than those in groups II [P <0.05] and III [P <0.01] during the 24-hr postoperative period. Groups II and III did not differ from each other in the incidence of PONV and the proportion of patients who requested rescue antiemetics. We thus conclude that prophylactic IV dexamethasone 8 mg significantly reduces the incidence of PONV in women undergoing abdominal hysterectomy. At this dose, dexamethasone is more effective than metoclopramide 10 mg or placebo