Trauma profile at a tertiary intensive care unit in Saudi Arabia

Trauma is a leading cause of death worldwide and in Saudi Arabia. This study describes the injury profiles and ICU outcomes of patients in a tertiary trauma care referral center in Riyadh, Saudi Arabia. A retrospective analysis of ICU data collected prospectively over 5 years in a 21-bed medical and surgical intensive care unit [ICU] in a tertiary care teaching hospital. We collected ICU data on all patients admitted secondary to motor vehicle accidents [MVAs], excluding patients younger than 18 years, brain dead patients and readmissions. We collected data on age, gender, and Glasgow coma scale score at admission, injury severity scores at admission, injury severity scores, Acute Physiology and Chronic Health Evaluation II [APACHE II] score, and other data. Multivariate logistic regression was used to identify predictors of mortality. During the study period, of 1659 patients, MVA was the most common cause of injury [78.4%], followed by pedestrian accident [12.7%]. ICU mortality included 221 patients [13.3%] during the study period. Severe head injury, age >60 years, Glascow coma scale score, injury severity scores, APACHE II and international normalized ratio were independent predictors of mortality. MVA is very common in our country and leads to significant mortality and morbidity. Public education and strict law enforcement are needed to reduce these adverse events

Sedation in ICU: are we achieving goals?

The purpose of this study was to examine whether sedation goals, utilizing a validated sedation assessment scale, the Riker Sedation-Agitation Scale [SAS], and a standardized sedation protocol, were achieved in Intensive Care Unit [ICU] patients. This is a nested prospective cohort study. The study was conducted in a tertiary care medical-surgical ICU. All mechanically ventilated adult patients who were judged by their treating intensivists to require intravenous sedation for more than 24 hours, were included in the study. A goal-directed protocol using the SAS was initiated following an educational program to the medical and nursing staff. The following data was collected: patients' demographics, Acute Physiology and Chronic Health Evaluation [APACHE] II score, reason for admission, and outcome. For the first five ICU days, the bedside nurse documented ordered and average achieved SAS scores, every 4 hours. We compared the targeted versus achieved SAS scores using a paired Student's t-test. One hundred and five [105] patients were included in the study with mean age [ +/- SD] of 47 [ +/- 23] and APACHE II [ +/- SD] of 21 [ +/- 9]. Achieved sedation scores were consistently lower than the requested goals during daytime and nighttime shifts throughout the study period. This did not change even after 3 months of implementing the protocol. Achieved levels of SAS score were consistently lower than what was requested by physicians despite an educational program and the use of a standardized protocol. Differences between targeted and achieved SAS scores persisted throughout the whole study period even three months after protocol implementation. These data suggest the need for alternative, more sensitive and precise approaches, to titrate sedation to targeted levels

Tachyphylaxis to cisatracurium-Case reports and literature review

Nondepolarizing neuromuscular blocking agents [NNMBAs] are commonly used in the intensive care unit [ICU], mainly to facilitate mechanical ventilation in critically ill patients who are not responding to sedatives and analgesics alone. Tachyphylaxis, also referred to as resistance, may develop during long-term infusion of NNMBAs. Several case reports of tachyphylaxis to NNMBAs have been reported. Although the definite mechanisms of tachyphylaxis to NNMBAs are not clear, several pharmacodynamic and pharmacokinetic changes have been described with the development of resistance. Tachyphylaxis to NNMBAs is associated with adverse outcomes including inadequate ventilation, increased risk of dose-dependent side effects, and increased drug costs. Patients who develop tachyphylaxis to one NNMBA should be treated with another NNMBA if neuromuscular blockade [NMB] is still indicated. We report three cases of tachyphylaxis to cisatracurium in a surgical intensive care unit [SICU]: one in patient with acute respiratory distress syndrome [ARDS] and the other two with traumatic brain injury [TBI]

Changing sedation practices in the intensive care unit- protocol implementation, multifaceted multidisciplinary approach and teamwork

Sedation protocols have demonstrated effectiveness in improving ICU sedation practices. However, the importance of multifaceted multidisciplinary approach on the success of such protocols has not been fully examined. The study was conducted in a tertiary care medical-surgical ICU as a prospective, 4-pronged, observational study describing a quality improvement initiative that employs 2 types of controlled comparisons: a [before and after] comparison related to intense education of ICU clinicians and nurses about sedation and analgesia in the ICU, and a comparison of protocolized versus non-protocolized care. Patients were assigned alternatively to receive sedation by a goal-directed protocol using the Riker Sedation-Agitation Scale [SAS] or by standard practice. A multifaceted multidisciplinary educational program was initiated including the use of point of use reminders, directed educational efforts, and opinion leaders. This included several lectures and in-services and the routine availability of at least one member of this group to answer questions. We included all consecutive patients receiving mechanical ventilation, who were judged by their treating team to require intravenous sedation. The following data was collected: demographics, Acute Physiology and Chronic Health Evaluation [APACHE] II score and Simplified Acute Physiology score [SAPS] II, daily doses of analgesics and sedatives, duration of mechanical ventilation, ICU length of stay [LOS] and ventilator associated pneumonia [VAP] incidence. To examine the effect of the multifaceted multidisciplinary approach, we compared the first 3 months to the second 3 months in the following 4 groups: Gl no protocol group in the first 3 months, G2 protocol group in first 3 months, G3 no protocol group in the second 3 months, G4 protocol group in the second 3 months. After ICU day 3, SAS in the groups G2, G3 and G4 became higher than in Gl reflecting [lighter] levels of sedation. There were significant reductions in the use of analgesics and sedatives in the protocol group after 3 months. This was associated with a reduction in VAP rate and trends towards shorter mechanical ventilation duration and hospital length of stay [LOS]. The implementation of a multifaceted multidisciplinary approach including the use of point of use reminders, directed educational efforts, and opinion leaders along with sedation protocol led to significant changes in sedation practices and improvement in patients' outcomes. Such approach appears to be critical for the success of ICU sedation protocol

Percutaneous tracheostomy in a patient with mandibulo maxillary interfixation with modified approach for bronchoscopic guidance

Percutaneous tracheostomy has replaced the surgical approach in many intensive care unit patients. In this case report, we present the use of percutaneous tracheostomy on a patient with mandibulo-maxillary interfixation. A 19-year-old male with severe maxillofacial injuries underwent mandibulo-maxillary interfixation. Percutaneous tracheostomy was planned. Because of the mandibulo-maxillary interfixation, however, neither direct laryngoscopy nor the fiberoptic bronchoscopy through the existing preformed nasal endotracheal tube could be utilized. A modified approach utilizing the fiberoptic bronchoscopy to safely withdraw the endotracheal tube was used. The bronchoscope was introduced from the other nostril and used to inspect the withdrawal of the ETT from outside. Our case demonstrates the feasibility of percutaneous tracheostomy in the setting of mandibulo-maxillary interfixation. To our knowledge this is the first report of percutaneous tracheostomy in this indication

[Prevalence and causal factors of anemia in children in Tunisia]

Anemia continue to be prevalent among children under five years despite the improvement of socioeconomic and sanitary indicators. The purpose of the present cross-sectorial study is to assess the etiologic factors responsible for anemia. Knowledge of the relative importance of the different causes should form a basis for intervention strategies to prevent and control anemia. The survey covered 955 children under the age of five years, native of two regions with the highest prevalence of anemia, the Southwest and the District of Tunis. The results showed that 29% of children suffered from anemia. About 70% of them were iron deficient. The fractions of the deficiency in vitamin B 12 and in folates were insignificant Only 3% of children had chronic inflammation associated with [and possibly responsible for] their anemia A little fraction of anemia [=5%] was due to thalassemia or drepanocytosis. Picawasan important causal factor of iron deficiency anemia. The parasites identified in stool could not cause anemia