Dexmedetomidine in cardiac anesthesia

There is an ever increasing number of invasive cardiovascular procedures performed annually all over the world. Most of these procedures are known to have a high complication rate; the most common cause of these complications being the surgical stress response with resultant impaired myocardial oxygen supply and demand ratio. The use of dexmedetomidine in cardiac anesthesia has shown promising results in decreasing the complication rates in these patients. It is shorter acting, highly selective alpha-2 adrenoceptor agonist and has analgesic, sedative, anxiolytic and sympatholytic properties. Published studies and meta-analyses have demonstrated beneficial role of perioperative use of dexmedetomidine in cardiac anesthesia. It is relatively a new drug and in order to further confirm its beneficial effects during cardiac anesthesia, more well designed, clinical trials are needed to make evidence based recommendations for its use in specific circumstances and establish its permanent place in cardiac anesthesia

Prepare today for tomorrow

There has been a rapid advancement in cardiac surgery and anesthesia recently. The burden of cardiothoracic disease in south East Asia especially in Pakistan is on the rise. To meet the challenges of future, the present day cardiologist, cardiothoracic surgeons and cardiothoracic anesthesiologists should be equipped with knowledge and expertise to train work force for future capable to treat the burden of cardiothoracic diseases. The future of cardiothoracic surgery and anesthesia is dependent on the advancements made in recent years in this specialty. It is time that the cardiothoracic anesthesiologists of the country embrace technologies such as transesophageal echocardiography and extracorporeal membrane oxygenation so that they can help in providing safe anesthesia and post-operative care for complex cardiothoracic operations

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

APACHE II analysis of a surgical intensive care unit population in a tertiary care hospital in Karachi [Pakistan]

Performance of prognostic models deteriorates over time by changes in case-mix and clinical practice. This study was conducted to describe the case-mix of a surgical intensive care unit [SICU] and assess the performance of APACHE II scoring system in this cohort. We analyzed 213 adult patients admitted to the surgical intensive care unit [SICU] of Aga Khan University Hospital, from January 2011 to December 2012 and the performance of APACHE II scoring system was assessed in this population. The mean age of patients was 46.31 years [SD +/- 18.43], 67.1% patients were male and mean length of ICU stay was 6.54 days [SD +/- 7.18]. Admissions to SICU were from seven service departments with the highest admissions from general surgery followed by trauma and neurosurgery. The mean APACHE II score of this SICU population was 15.89 [SD +/- 8.06], 12.88 [SD +/- 6.29] in survivors and 22.24 [SD +/- 7.66] in non-survivors [p <0.01]. The overall mortality was 33%, with SMR of 1.0. No patient survived with an APACHE II score of more than 34. In this SICU population the calibration and discrimination of the APACHE II scoring system was acceptable, i.e. [[H-LS 11.76 [p=0.l6]] and [area under the receiver operating curve = 0.83]. APACHE II scoring system allows meaningful analysis of SICU population, therefore, it is recommend, that this simple and cost effective scoring system should be used to identify patients with high risk of death to justify the decisions of withholding expensive therapies in resource limited settings

review of critical care management of maternal sepsis

Sepsis is a leading cause of preventable maternal mortality in developing countries due to poverty, home deliveries by untrained persons in unhygienic conditions, limited access to healthcare facilities and lack of availability of antibiotics. Recent confidential enquiries into maternal deaths from the developed nations have revealed an increase in maternal mortality secondary to genital tract sepsis and provision of suboptimal critical care. Early recognition of critical illness in obstetric patients, involvement of intensive care teams earlier and provision of same standard of critical care to pregnant women as non-pregnant patients while being mindful of the altered maternal physiology and fetal wellbeing is necessary to improve outcome of this vulnerable population.This article reviews the definitions and risk factors of maternal sepsis and describes the standards recommended for efficient delivery of maternal critical care and sepsis management

Apache-II score correlation with mortality and length of stay in an intensive care unit

To correlate the APACHE-II score system with mortality and length of stay in ICU. Cohort study. The Intensive Care Unit [ICU] of the Aga Khan University Hospital, Karachi, from May 2005 to May 2006. All adult patients who were admitted in the ICU were included. APACHE-II score was calculated at the second and seventh days of admission in the ICU. Patients who were discharged alive from the ICU or died after first APACHE-II Score [at 2nd day] were noted as the primary outcome measurement. Second APACHE-II score [at 7th day] was used to predict the length of stay in the ICU. Pearson's correlation coefficient [r] was determined with significance at p < 0.05. In the lowest score category 3-10, 27 out of 30 patients [90%] were discharged and only 3 [10%] died. Out of those 39 patients whose APACHE-II score was found in high category 31 - 40, 33 [84.6%] deaths were observed. This revealed that there might be more chances of death in case of high APACHE-II score [p=0.001]. Insignificant but an inverse correlation [r = -0.084, p < 0.183] was observed between APACHE-II score and length of ICU stay. The APACHE-II scoring system was found useful for classifying patients according to their disease severity. There was an inverse relationship between the high score and the length of stay as well higher chances of mortality

Grown up Congenital Heart Disease patient presenting for non cardiac surgery: anaesthetic implications

Congenital heart disease patients surviving to adulthood have increased over the years due to various reasons. These patients are admitted in the hospital for non cardiac surgeries and other procedures more often than normal adult population. Management of grown up congenital heart disease patient presents a challenge during perioperative period for cardiologists, surgeons, intensivists and particularly for the anaesthetist. Management issues include psychological and physiological impact on the patient, complexity of defects, presence of previous palliative procedure, impact of anaesthetic agents on shunting and myocardium, endocarditis prophylaxis and associated extra cardiac anamolies

Outcome of home mechanical ventilation

To determine the outcome of patients discharged home on portable ventilator. The Aga Khan University Hospital, Karachi from January 2000 to December 2004. All ventilator-dependent patients discharged home were contacted. Survivors were administered the EQ-5D Quality-of-Life instrument. SPSS version 13 was used to analyze data. Eleven patients were discharged home on invasive ventilation. Mean age was 49 years [range10-98 years]. Cause of ventilatory failure were cervical spine trauma in 36%, primary neurological disease in 27%, critical illness neuropathy and respiratory failure in 18% each. Survival rate was 73%, with three deaths. Mean duration of ventilation was 9.45 months [95% CI 3.24, 15.67]. Rate of successful weaning after discharge was 36%, with 4 patients off all forms of ventilatory support and 2 on only nocturnal support. A 2.8 [95% CI 0.5, 16.6] relative risk towards successful weaning was associated with the presence of a family member as the primary care giver. Mean scores on the EQ-5D descriptive tool were; mobility 2 [ +/- 0.82], self-care 2 [ +/- 0.82], usual activities 1.86 [ +/- 0.69], pain/discomfort 1.43[ +/- 0.79], anxiety/depression 1.29 [ +/- 0.76]. Mean score on the EQ-VAS was 48.2[ +/- 27.3]. In carefully selected patients, home ventilation is a viable option with the expectation of successful weaning and survival. Patients discharged home on ventilation reported a reasonably good quality of life with proportionately more problems related to independence compared to overall well-being