Improving the care of sepsis: between system redesign and professional responsibility: a roundtable discussion in the world sepsis day, September 25, 2013, Riyadh, Saudi Arabia

This paper summarizes the roundtable discussion in September 25, 2013, Riyadh, Saudi Arabia as part of the World Sepsis Day held in King Abdulaziz Medical City, Riyadh. The objectives of the roundtable discussion were to [1] review the chasm between the current management of sepsis and best practice, [2] discuss system redesign and role of the microsystem in sepsis management, [3] emphasize the multidisciplinary nature of the care of sepsis and that improvement of the care of sepsis is the responsibility of all, [4] discuss the bundle concept in sepsis management, and [5] reflect on the individual responsibility of the health care team toward sepsis with a focus on accountability and the moral agent

Pre-hospital and initial management of head injury patients: an update

Most of the bad outcomes in patients with severe traumatic brain injury [TBI] are related to the presence of a high incidence of pre-hospital secondary brain insults. Therefore, knowledge of these variables and timely management of the disease at the pre-hospital period can significantly improve the outcome and decrease the mortality. The Brain Trauma Foundation guideline on "Prehospital Management" published in 2008 could provide the standardized protocols for the management of patients with TBI; however, this guideline has included the relevant papers up to 2006. A PubMed search for relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic, was conducted. Based on the evidence, majority of the management strategies comprise of rapid correction of hypoxemia and hypotension, the two most important predictors for mortality. However, there is still a need to define the goals for the management of hypotension and inclusion of newer difficult airway carts as well as proper monitoring devices for ensuring better intubation and ventilatory management. Isotonic saline should be used as the first choice for fluid resuscitation. The pre-hospital hypothermia has more adverse effects; therefore, this should be avoided. Most of the management trials published after 2007 have focused mainly on the treatment as well as the prevention strategies for secondary brain injury. The results of these trials would be certainly adopted by new standardized guidelines and therefore may have a substantial impact on the pre-hospital management in patients with TBI

General intensive care for patients with traumatic brain injury: an update

Traumatic brain injury [TBI] is a growing epidemic throughout the world and may present as major global burden in 2020. Some intensive care units throughout the world still have no access to specialized monitoring methods, equipments and other technologies related to intensive care management of these patients; therefore, this review is meant for providing generalized supportive measurement to this subgroup of patients so that evidence based management could minimize or prevent the secondary brain injury. Therefore, we have included the PubMed search for the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. General supportive measures are equally important to prevent and minimize the effects of secondary brain injury and therefore, have a substantial impact on the outcome in patients with TBI. The important considerations for general supportive intensive care unit care remain the prompt reorganization and treatment of hypoxemia, hypotension and hypercarbia. Evidences are found to be either against or weak regarding the use of routine hyperventilation therapy, tight control blood sugar regime, use of colloids and late as well as parenteral nutrition therapy in patients with severe TBI. There is also a need to develop some evidence based protocols for the health-care sectors, in which there is still lack of specific management related to monitoring methods, equipments and other technical resources. Optimization of physiological parameters, understanding of basic neurocritical care knowledge as well as incorporation of newer guidelines would certainly improve the outcome of the TBI patients.

Specific intensive care management of patients with traumatic brain injury: present and future

Traumatic brain injury [TBI] is a major global problem and affects approximately 10 million peoples annually; therefore has a substantial impact on the health-care system throughout the world. In this article, we have summarized various aspects of specific intensive care management in patients with TBI including the emerging evidence mainly after the Brain Trauma Foundation [BTF] 2007 and also highlighted the scope of the future therapies. This review has involved the relevant clinical trials and reviews [from 1 January 2007 to 31 March 2013], which specifically discussed about the topic. Though, BTF guideline based management strategies could provide standardized protocols for the management of patients with TBI and have some promising effects on mortality and morbidity; there is still need of inclusion of many suggestions based on various published after 2007. The main focus of majority of these trials remained to prevent or to treat the secondary brain injury. The future therapy will be directed to treat injured neurons and may benefit the outcome. There is also urgent need to develop some good prognostic indicators as well.

multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center

A multidisciplinary team was formed to improve hand hygiene [HH] practices in a tertiary-care ICU. At baseline, an audit revealed that the overall HH compliance was 64% and was significantly lower at night than during the day shift. After implementing a stepwise multifaceted approach that included education, workplace reminders, active feedback and later universal contact precautions, the HH compliance improved significantly to >80%, and the improvement was sustained over several months. This improvement was noted during the day and night and affected different healthcare workers as well as visitors

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

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

safety of percutaneous tracheostomy in patients with coagulopathy or thrombocytopenia

The safety and complications of percutaneous tracheostomy [PT] without bronchoscopic guidance in a group of ICU patients with thrombocytopenia platelet count of /= 1.5 or systemic heparinization], was studied. During the study period [May 2004-June 2005], 190 percutaneous tracheostomies were performed. Of these there were 11 [6%] patients with prolonged INR, 7 [4%] patients with thrombocytopenia and 14 [7%] patients on systemic heparin. There was no evidence of bleeding in patients with prolonged INR. A minor bleeding developed in only one patient with thrombocytopenia, and in two patients receiving systemic heparin. The PT was aborted for one patient with thrombocytopenia and slight increase of INR [1.3] due to major bleeding in spite of transfusion of both platelets and FFP. Our data suggest the incidence of bleeding is low in patients with coagulopathy and or thrombocytopenia-undergoing PT without bronchoscopic guidance

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

challenge of a multicultural environment for critical care nursing in Saudi Arabia

With a worldwide shortage of critical care nurses and the alluring opportunity for nurses to work abroad, it can be said that the multicultural experience associated with working in Saudi Arabia may not be unique to the Kingdom. Healthcare staff is faced with many challenges in a multicultural environment in relation to language, customs, communication, and healthcare practices. In this article it is endeavored to discuss these challenges and to suggest some possible solutions to the problems encountered

Hypokalemic paralysis mimicking Guillian Barre syndrome and causing acute respiratory failure

A 33-year-old female patient admitted to the ICU with ascending muscle weakness leading to acute hypercapneic respiratory failure. She gave a 10-day history of severe diarrhea and vomiting. Laboratory work up revealed severe hypokalemia, mixed metabolic and respiratory acidosis, and renal impairment. Continuous potassium replacement produced rapid and complete recovery from quadriplegia and respiratory failure without requirement for mechanical ventilation

Improving resource utilization in the intensive care units a challenge For Saudi hospitals

In the face of increasing demand of intensive care services in the Kingdom of Saudi Arabia, as well as the high cost of delivering such services, systematic steps must be undertaken in order to ensure optional utilization and fair allocation of resources. Strategies start prior to intensive care units [ICU] admission by the proper selection of patients who are likely to benefit from ICU. Less resource-demanding alternatives, such as intermediate care units, should be used for low-risk patients. Do-not-resuscitate status in patients with no meaningful chance of recovery will prevent futile admissions to ICUs. Measures known to improve the efficiency of care in the ICU must be implemented, including hiring full-time qualified intensivists, switching open units to closed ones and the introduction of certain evidence-base driven management protocols. On discharge, the intermediate care units again play a role as less expensive alternative transitional area for patients who are not stable enough to go to general ward. Measures to reduce re-admissions to ICU must also be implemented. Improving ICU resource utilization requires teamwork not only the intensivists but also the administrators and other health care providers