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

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

Post operative throat complications after general anesthesia, a comparison between laryngeal mask airway and endotracheal tube

To determine the incidence of post operative throat complications such as pain dvsphagia, hoarseness of voice, dryness of throat and cough, after general anesthesia, and to compare between laryngeal mask airway and endotracheal tube. Prospective, double blinded, comparative, randomized observational study. Department of Anesthesiology and Surgical Intensive Care Unit, Civil Hospital Karachi, over a period of one year. 150 randomly selected A.S.A I and A.S.A II patients receiving general anesthesia were divided into two groups, 75 patients in each group. One group receiving general anesthesia through endotracheal tube and other group through laryngeal mask airway. This study was based on two proformas 1. Intra operative proforma. 2. Post operative proforma. This study has shown that the incidence of post operative throat complications after general anesthesia are 51/150 [34%] i.e 35/75 [46.6%] with endotracheal tube and 16/75 [21.3%] with laryngeal mask airway. General Anesthesia with laryngeal mask airway is associated with lesser number of throat complications as compared to endotracheal tube

Comparison between the time required to obtain maximum recovery point [10] after intravenous induction of general anesthesia with injection midazolam and injection thiopentone sodium in day case urological procedures

The objective of this study was to determine whether injection Midazolam could produce similar anesthesia, characterized by short duration of actions and clear headed and rapid recovery. Midazolam was compared with Thiopentone Sodium during day case short urological procedures. This was a prospective, single blinded, comparative, randomized, observational study. It was conducted in the Department of Anesthesiology and Surgical I.C.U, Civil Hospital Karachi and Dow Medical College, over a period of one year. Hundred randomly selected A.S.A I and A.S.A II patients receiving general anesthesia, were divided into two groups. 50 patients in each group, group I receiving injection Midazolam and the other, group II receiving injection Thiopentone Sodium, as IV induction agents, all patients received injection Pentazocine 0.3mg /kg and Injection Suxamethonium 1-1.5 mg/kg and anesthesia maintain with 02 + N2O+Halothane. At the end of surgical procedure all anesthetic agents were discontinued. Patients were extubated when they responded to verbal commands. Recovery from anesthesia was assessed by an evaluator who was unaware of the IV induction agents used for each patient. This study was based on two proforma I]. Intra operative proforma II] Recovery Room proforma. In group I [Midazolam group] after 5 and 10 minutes, no patient received 10 recovery points, after 20 minutes 6 patients received 10 recovery points and after 30 minutes 26 patients received 10 recovery points and those who didn't score 10 points after 30 minutes were 18 patients. In group II [Thiopentone Sodium group] after 5 minutes 1 patient, after 10 minutes 2 patients, after 20 minutes 22 patients, after 30 minutes 23 patients received 10 recovery points, patients who didn't score 10 points after 30 minutes were just 2. After induction with injection Thiopentone Sodium recovery is more rapid as compared to the induction with injection Midazolam, so injection Thiopentone Sodium is the better of the two drugs under comparison for day case urological procedures

Organophosphorus insecticide poisoning: management in surgical intensive care unit

To evaluate the outcome of patients with organophosphorus poisoning. Descriptive [non-interventional] study. Surgical Intensive Care Unit, Civil Hospital Karachi, from January 1996 to December 2002. Medical records of all the patients with organophosphorus poisoning, admitted during the study period, were reviewed. Their clinical features, complications, management and survival were noted. Out of 52 patients, admitted to surgical intensive care unit during the study period, 92.31% survived and were discharged to medical wards. Major cause of mortality [7.69%] was acute respiratory distress syndrome. The common cause of mortality in organophosphorus poisoning is aspiration pneumonia leading to acute respiratory distress syndrome that is preventable by securing the airway early in emergency room

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

Comparison of caudal bupivacaine and bupivacaine-midazolam for peri and postoperative analgesia in children

To compare the duration and side effects of postoperative analgesia of caudal bupivacaine and bupivacaine-midazolam mixture. Design: Single blinded, interventional experimental study. Place and Duration of Study: The Department of Anesthesiology and Surgical Intensive Care Unit, Dow Medical College and Civil Hospital, Karachi from May to November, 2002. Subjects and Sixty children, aged 1-8 years, ASA physical status I and II, undergoing inguinal and urogenital surgery were randomly allocated to receive either 0.25% bupivacaine 0.75 ml/kg [group A] or 0.25% bupivacaine 0.75 ml/kg along with 0.1% midazolam 50mg/kg [group B] by caudal route immediately after induction of general anesthesia. Anesthesia was maintained till the end of surgery. Cardiorespiratory data, sedation and pain score were recorded for 24 hours following recovery from anesthesia. Analgesia was supplemented [diclofenac suppository] whenever the pain score was > or = 4. Duration of analgesia was recorded. The duration of analgesia was 21.41 + 2.7 hours in bupivacaine midazolam group and 9.97 + 2.25 hours in bupivacaine group, which showed a significant difference [p < 0.001]. There was no significant difference in heart rate, respiratory rate, blood pressure and the incidence of side effects in both groups [p = 0.716]. The sedation score were significantly higher in bupivacaine-midazolam group during first hour postoperatively [*p = 0.003]. Addition of midazolam to caudal bupivacaine provides longer duration of postoperative analgesia without having significant side effects but with higher sedation score for 1 hour postoperatively