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

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