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

Intralesional bleomycin injection- A primary therapy for peripheral lymphangiomas

To evaluate the efficacy of intralesional Bleomycin Injection [IBI] as a primary therapy for peripheral lymphangiomas in children. A prospective study was conducted at NICH Karachi from January 2003 to December 2005. Patients with peripheral lymphangiomas were included in the study. Exclusion criteria included previously treated lymphangiomas, infected lesions, intra-thoracic and intra-abdominal lesions. Thirty three patients were included in the study. All were treated with Intralesional Bleomycin Injection [IBI]. After aspiration of fluid from the lesion, 0.5 mg/kg of Bleomycin diluted in saline was administered at different sites into the lesion. Depending upon the size of lesion and age of patient, procedure was performed in operating theatre under local or general anesthesia. Reduction in size was seen in 90% cases [n=29], out of them 30% [n=10] showed near complete disappearance and 63% [n=21] showed good response. Two patients [6%] showed poor response and they underwent surgery. Few patients had minor complications like fever, pain, redness and increase in the size after injection. All these complications were managed conservatively with symptomatic treatment and no patient required hospitalization. IBI is an effective therapy for lymphangiomas, with results comparable to surgical excision. It has the added advantage of avoiding inadvertent injury to vital structures, scarring and other complications of surgery. We recommend it as a primary therapy for all peripheral lymphangiomas

Complications of tracheostomy

A study of 44 tracheostomies was conducted at Combined Military Hospital Rawalpindi to see the complications. All tracheostomies were performed under general or local anaesthesia in operation theatre. Portex cuffed tracheostomy tube was used in 83.6%, Vygon [PVC] tracheostomy tube in 9% and Chevalier-Jackson tracheostomy tube in 4.5% cases. The rate of complications was 27.2%. The intermediate complications included surgical emphysema and infection of the wound. There was no death related to tracheostomy however, deaths not related to tracheostomy were 20.35%