Effectiveness of intensive insulin therapy in the management of acute necrotizing pancreatitis induced by very severe hypertriglyceridemia

Hypertriglyceridemia may be responsible for up to 4% of acute pancreatitis. Complicated pancreatitis is a serious medical condition and might be fatal. Therefore, treating the underlying cause along with supportive measures is crucial to prevent further deterioration and possible death. There have been reports where Insulin has been the mainstay of treatment for reducing triglyceride levels in patients with pancreatitis, however, there are no well-established guidelines. We present a forty-year-old female patient diagnosed with acute necrotizing pancreatitis. CT abdomen revealed acute necrotic pancreatitis [Balthazar E] with extensive peri-pancreatic and peritoneal fluid collections. The patient was managed in the ICU for 28 days. She continued to receive gemfibrozil and insulin infusion, initiated according to the ICU's Protocol - Algorithm 1 targeting glucose values of 4.4 mmol/L to 10 mmol/L along with heparin infusion. She was successfully treated and recovered. She was discharged on antidiabetic and lipid lowering medications

Misunderstanding of the term [DNR] in a middle-eastern teaching hospital

Do-not-resuscitate [DNR] order has been practiced for many years; though it is one of the most commonly misunderstood and misinterpreted orders in medical practice. It has many ethical, legal, geographic, religious and cultural aspects that contribute to this misunderstanding. To assess the perception amongst the acute specialties who deal with DNR orders. A Cross-Sectional Questionnaire Type Study. Setting: King Hamad University Hospital, Bahrain. Anonymous questionnaire was designed. Physicians working in the acute specialties were included. The questionnaire included several general questions about when DNR should be implemented and what are the appropriate aspects of management that should be given. Fifty doctors completed the questionnaire; 49 [98%] of the physicians thought that a hospital should have a DNR policy, 23 [46%] of the physicians believed that the DNR decision lies in the hands of the responsible doctor, 10 [20%] of the participants thought that it is a family decision only, whilst 17 [34%] thought that it is a joint decision by the family and the physician. All of the physicians agreed that there should be no code blue activation in case of cardiopulmonary arrest of a DNR labeled patients. The term DNR should not be used as it is confusing and liable to misunderstanding. In addition, we need to educate healthcare professionals about the terminology of the management of end-of-life situations

Metabolic Acidosis and Rhabdomyolysis with Metformin overdosage

Metformin is a biguanide oral hypoglycemic agent used as first-line or as a part of multi-drug therapy in the treatment of Type 2 Diabetes Mellitus [DM]. Lactic acidosis is a well-known but relatively uncommon adverse effect of Metformin, especially in patients with co-existing renal failure. There are several case reports of inadvertent or intentional Metformin overdosage resulting in severe metabolic acidosis with hyperlactatemia and often fatal outcome. Continuous hemodiafiltration with other supportive therapies have resulted in successful management of the metabolic derangements and is presently the accepted standard therapy of Metformin intoxication. A twenty-two-year-old female presented with Metformin over-dosage of 50g and developed severe metabolic acidosis and rhabdomyolysis. Metabolic acidosis was prolonged; the pH level was 6.72, bicarbonate level <4 mmol/L and lactate level was more than 25 mmol/L. The patient was managed with crystalloids, bicarbonate infusions and continuous venovenous hemodiafiltration. The blood gas parameters normalized 48 hours after initiation of the treatment. Hemodiafiltration was continued for longer than usual due to the prolonged metabolic acidosis and until the elevated Creatine Kinase [CK] levels returned to normal. She made an uneventful recovery, without residual sequelae

Status Epilepticus: an intractable case with a successful outcome

A thirty-two-year-old male patient with a history of fever presented with generalized tonic-clonic convulsions and a low Glasgow Coma Score [GCS]; an endotracheal tube was inserted to secure his airway. The patient had malignant generalized tonic-clonic convulsions for six weeks, he was diagnosed as status epilepticus [SE] on the electroencephalogram [EEG]. Achieving control was very difficult even with various antiepileptic medications. More than six antiepileptic drugs were used in addition to continuous infusion of anesthetic medications to control the convulsions. After four-months in the ICU, the patient became fully conscious with no residual neurological deficit and good control of convulsions but with generalized muscle weakness. The patient was eventually transferred to the regular ward and was discharged after few days

Development and evaluation of a medical communication scale

To evaluate the degree of communication with patients and their relatives based on a predesigned medical communication scale. A Prospective random sample assessment study. Intensive Care Unit, King Hamad University Hospital. We studied the scale randomly in 50 adult patients admitted to ICU. The degree of communication with the patient's next of kin was assessed by a native English speaking intensivist according to a scale designed for the purpose. Twenty-three [46%] relatives required the help of an interpreter for communication [class 4]. Full communication was possible with 15 [30%] relatives [class 2]. Twelve [24%] relatives did not have a full grasp of the working language or were informed to a below average level or were unwilling or uninterested in obtaining further knowledge. There was no relative with whom communication was impossible [class 5] nor was there any well-informed relative with whom communication was fully fluent [class 1]. The medical communication scale can help the physician to objectively quantify the ease or difficulty in communication with the patient's relatives. In the ethnically mixed workforce of our hospital, while the physician could fully communicate with many relatives, a significant percentage of the relatives were not proficient in the working language of the hospital and required the help of an interpreter to communicate with the physician