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

Two forgotten induction agents; etomidate versus thiopental sodium with rocuronium for rapid sequence induction

To assess the effect on intubating conditions and haemodynamic response on intubation of two different induction agents etomidate and thiopental sodium with rocuronium during rapid sequence induction. This prospective quasi experimentalstudy was conducted in Department Of Anaesthesia, SICU and Pain Management, Dow Medical College, Civil Hospital Karachi and Abbasi Shaheed Hospital Karachi Medical and Dental College over a period of one year. Total 120 American Society of Anaesthesiologists [ASA] physical class I and II, adult patients of either gender, aged between 18 to 60 years, undergoing elective surgery were allocated randomly into two equal groups to receive either intravenous thiopental sodium [Group NTR] or etomidate[Group NER] for rapid sequence induction. Group NER was given nalbuphine 0.1 mg/kg, induction agent etomidate 3 mg/kg with muscle relaxant rocuronium 1.0 mg/kg while in group NTR induction agent thiopental sodium was given in the dose of 4 mg/kg with nalbuphine and rocuronium in the same doses. After sixty seconds, laryngoscopy was done. Intubating condition was assessed using the criteria of Cooper and colleagues: ease of intubation, condition of vocal cords and response to intubation. Cardiovascular response on intubation in terms of systolic and diastolic blood pressure and heart rate was evaluated at 0,1, 3 and 5 minutes. Demographic data were comparable between the groups. Intubating conditions which were assessed in terms of ease of laryngoscopy, condition of vocal cords at intubation and intubation response coughing, bucking and diaphragmatic movement were significantly better in the group NER [p<0.05]. Similarly, arterial blood pressure remained close to base line in NER group but there was significant fall in both systolic and diastolic blood pressure in group NTR. However, there was no significant difference in change in the heart rate in the groups. Etomidate-rocuronium is better than thiopental-rocuronium in terms of intubating conditions and haemodynamic stability during rapid sequence induction in non-septic surgical patients in emergency department

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

Comparison of intravenous ketorolac with diclofenac for postoperative analgesia

To compare analgesic effect and complications of non - steroidal anti-inflammatory drugs [NASIDs], ketorolac versus diclofenic in prevention of pain after laparoscopic cholecystectomy. Quasi-experimental study. The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College, Karachi from March 2003 to March 2004. Sixty patients, ASA physical status I and II were selected to received either ketorolac 30 mg intravenous [group A] or diclofenic 75 mg intravenous [group B], after general anesthesia induction and before surgical incision. In ketorolac group same dose repeated three times daily for 24 hours. The diclofenic group received diclofenic 75mg 12 hourly for 24 hours. Analgesic effect assessed by intensity of pain postoperatively using visual analogue scale, 0 mean no pain and 10 most severe pain. Rescue analgesic nalbuphine was administered if needed. Both groups required rescue analgesic 0.1mg/kg nalbuphine boluses postoperatively. Higher nalbuphine consumption was noted compared to diclofenic group until 12 hours, which is statistically significant [P value < 0.05]. Side effects were almost similar in both groups. Ketorolac and diclofenic are insufficient alone for analgesia after laparoscopic cholecystectomy; the total nalbuphine consumption was less in ketorolac group

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

assessment of risk factors for postoperative nausea and vomiting

To determine the risk factors for postoperative nausea and vomiting. Quasi-experimental study with prospective data collection. The study was conducted at Dow Medical College University and Civil Hospital, Karachi from January to December 2004. Data on patients' characteristic, anesthesia, surgery and postoperative nausea and vomiting was collected in operating theatre, postanesthesia care unit and wards. During postoperative 24 hours period, 60 out of a total of 200 patients experienced nausea and vomiting. The factors associated with an increased risk of Postoperative Nausea and Vomiting [PONV] were gender [female odds ratio 3], patients with previous history of nausea and vomiting or motion sickness [odds ratio 4], laparoscopic cholecystectomy [odds ratio 3.5] and eye surgery [odds ratio 3.9], all of these were statistically significant [p < 0.05]. No statistically significant difference was found between the other parameters. The incidence of PONV was found significantly higher in female gender, patients with previous history of nausea and vomiting or motion sickness, patient undergoing laparoscopic cholecystectomy and eye surgery

Intrathecal isobaric versus hyperbaric bupivacaine for elective Caesarean section

To compare the results of isobaric bupivacaine [0.5%] with hyperbaric bupivacaine [0.75%] in cases of elective Caesarean Section, in respect of time to sensory analgesia, highest level of sensory block, haemodynamic effects, and complications. Interventional, experimental study from March 2003 to March 2004. Department of Anaesthesiology and Surgical Intensive Care Unit, Dow University of Health Sciences and Civil Hospital, Karachi. Sixty pregnant patients scheduled for elective Caesarean Section. The patients were randomly assigned to receive either 0.5% isobaric bupivacaine [Group-1B] or 0.75% hyperbaric bupivacaine [Group-HB] via intrathecal route. The time of onset of block, highest level of sensory block, cardio-respiratory data, duration of analgesia and complications were recorded during surgery. Results: The time taken to reach T4 sensory analgesia in Group-IB was 6 +/- 6.43 minutes as compared to 6.93 +/- .7.8 minutes in Group-HB, while the highest sensory level achieved in Group-IB was TI and in Group-HB T2. The lowest systolic blood pressure recorded in Group-IB was 83.27 +/- 12.69 mmHg and in Group-HB 114.33 + 13.83 mm Hg, the difference being significant [p < 0.05]. There was a higher incidence of complications in Group-IB as compared to Group-HB like high spinal analgesia, vomiting and discomfort. Intrathecal block showed a greater reduction in the systolic blood pressure, and associated complications, with Isobaric Bupivacaine as compared to Hyperbaric Bupivacaine

Is mallampati scoring relevant in patients with oral cancers?

To assess the feasibility of successful endotracheal intuhation in patients with oral cancer with a Mallampati score of 4 with reasonable mobility of temporo-mandibular and atlantoaxial joints. ENT department, Civil Hospital Karachi, from March 2005 to March 2007. 25 patients, with orofacial cancers were chosen in which the Mallampati score was 4 and tracheal intubation was expected to be very difficult. In this study out of twenty five patients 24 pts [96%] were intubated successfully with Macintosh laryngoscope. Patients having Mallampati class 4 have a reasonable chance of undergoing successful endotracheal intubation provided their temporo-mandibular joints and atlantoaxial joints are mobile. Key Words: .Endotracheal intubation, Mallampati scoring

Comparison of fentanyl / isoflurane versus nalbuphine/isoflurane in patients undergoing elective coronary artery bypass surgery

To compare hemodynamic stability, efficacy and extubation time by using fentanyl / isoflurane versus nalbuphine / Isoflurane for coronary artery bypass surgery. Intervention experimental study. The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College and Civil Hospital, Karachi from April 2003 to April 2004. Sixty patients, both sexes, with ejection fraction not less than 40%, elective coronary artery bypass surgery were randomly allocated to receive either fentanyl / isoflurane or albuphine. Hemodynamic stability, drugs supplemented and extubation time were recorded. During intubation, skin incision and sternotomy systolic blood pressure was 126, 47 +/- 7.45, 127.97 +/- 7.58 and 127.03 +/- 7. 10 in group A fentanyl/isoflurane] and 167.60 +/- 14.41, 169.50 +/- 12.99 and 165.83 +/- 11.79 in group B nalbuphine/isoflurane] respectively with [p < 0.05] which is significant. To maintain hemodynamic stability in group B, supplementation with propofol and glyceryltrinitrate infusion was required. Extubation time in group A was 8.2113.87, and in group B was 6.15 +/- 3.41 with [p<0.05] which is significant. Fentanyl/isoflurane provides better hemodynamic stability than nalbuphine / isoflurane, but nalbuphme / isoflurane leads to earlier tracheal extubation than fentanyl / isoflurane group

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