Gynecology and obstetrical conditions requiring intensive care admission.

OBJECTIVE: Gynecological admissions to the surgical intensive care unit vary from the obstetrical cases. Pregnant women are of prime age and can tolerate the pregnancy and delivery well. There are certain rare conditions or complications, which make the pregnant women's life pass through a critical time. These are dealt with in a high dependency area, which is short of the intensive care unit. In King Khalid University Hospital there is no such arrangement, so the mildly affected and critically ill patients together are cared for in the surgical intensive care unit. The objective of this study is to study the gynecological and obstetrical conditions requiring intensive care admission in King Khalid University Hospital, surgical intensive care unit. METHODS: All obstetrical and gynecological patients who were admitted to the surgical intensive care unit were included. The demographic particulars, reason for admission, the course of the surgical intensive care unit stay and outcome were studied. RESULTS: During the study period of 3 years, there were 83, (100%) obstetrical and gynecological admissions to the surgical intensive care unit. Two (2%) cases were due to anesthesia complications. The majority of causes of admissions were due to obstetrical (n=63, 76%) complications or combination of medical and surgical conditions. Gynecological admissions comprised only 18 (22%) cases. There was no mortality in the group studied. CONCLUSION: Management of major obstetrical emergencies and gynaecological patients require an understanding of medical conditions' influence on the patients, and the physiological changes of normal and abnormal pregnancies. Intensive care unit management is an essential part in raising the level of patient care; health personnel training and continuing health care education may be improved.

15 years of experience with cardiopulmonary resuscitation in the Kingdom of Saudi Arabia: a critical analysis.

The objective of this review is to establish a framework about the educational activities of the Cardiopulmonary Resuscitation (CPR) National Committee of the Saudi Heart Association (SHA) and determine if it has had any effect on the survival rate in daily hospital work. Further, the review puts forward recommendations regarding the key to success for future implementations and improvement in the outcome of heart attacks in the Kingdom of Saudi Arabia (KSA). Cardiopulmonary resuscitation (CPR) was introduced into the Kingdom of Saudi Arabia in the 1980s. The birth of CPR in the Kingdom was conducted by the American Heart Association (AHA) provision of the first instructor course in Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) in the spring of 1984. This educational activity was initiated by the Postgraduate Center of the College of Medicine and currently is a function of the Saudi Heart Association (SHA). The National Heart Center (NHC) continually expands its activities. The number of courses organized, conducted, and reported herein totaled 459 for providers and instructors in BCLS and ACLS. This resulted in certification of 916 and 204 instructors in basic and advanced CPR respectively. There were 80 centers established in the Kingdom over the span of 15 years. They all provide BCLS courses; only 13 provide ACLS courses. The SHA issued a total of 84,659 certificates.

Critical incident reports.

We describe a retrospective analysis of critical incident reports in two teaching hospitals. We included significant observations, involving unsafe practices during cardio-pulmonary resuscitation intensive care management and during anesthesia. Of the 143 critical incidents reported, 87% did not lead to negative out-come, out of these 13% were reports on deaths of patient resuscitated by CPR team or emergency department, underwent surgery, and or managed in the intensive care unit. Human errors and lack of communications were common factors for the majority of the incidents. Wrong drug labeling and irresponsible behavior were the most frequent among the human errors. The analysis aimed to regularize the method of reporting and also to determine the causes of complications, offer solutions and prevent occurrence of such incidents in the future.

Heat exhaustion during mass pilgrimage--is there a diagnostic role for pulse oximetry?

Every year over 2 million pilgrims (Hajjis) gather from different countries to perform the sacred ritual, the fifth pillar of Islam, Hajj. Several nationalities from different climates come to Saudi Arabia which is located in a subtropical area with a hot and humid climate during the long summer season. This undertaking is characterised by several days of continuous physical, spiritual, and emotional exertion following their homeland. Several factors predispose them to heat exhaustion, such as the hot climate, excessive physical exercise, lack of acclimatisation, overcrowding, illiteracy, old age, diseases, and over zealous performance of Hajj during the peak sunshine hours. Several thousands of pilgrims suffer from heat exhaustion which is a minor form of heat illness that can easily be detected and treated. Patients are usually discharged having fully recovered, but if heat exhaustion is not treated immediately, it may result in heat stroke with serious sequelae. Cases that need further observation and management are admitted to hospital, particularly those who have associated medical disorders. This study was designed to investigate the role of pulse oximetry in detecting hypoxaemia in patients suffering from heat exhaustion. One hundred fifty-five patients from 26 different countries were enrolled in this study. Their ages ranged from 18 to 83 years. There were 51 (33%), 48 (31%), and 56 (36%) from Asia, the Middle East and Africa, respectively. One hundred thirty-four patients (86.5%) showed a form of hypoxia which necessitated O2 administration. Mild hypoxia (91-94% O2 saturation) was detected in 81 patients (52.3%) and moderate to severe hypoxia (< 90% O2 saturation) was detected in 53 (34.2%) patients.

The role of laryngeal mask airway in cardiopulmonary resuscitation.

The laryngeal mask airway (LMA) has been newly introduced to anaesthesia practice as an alternative to the endotracheal tube (ETT) or face mask for airway management. It is capable of providing a rapid and easily achieved patent airway that permits positive pressure ventilation within confined limits. In this study, we aim to evaluate the role of the LMA in cardiopulmonary resuscitation (CPR) in 20 patients as an alternative to tracheal intubation. Study parameters included measurement of oxygen saturation by a pulse oximeter and end-tidal carbon dioxide level (ETCO2) using the Fenem CO2 analyser. Five of these 20 cases were resuscitated using endotracheal tubes as a control group. Seven cases were resuscitated using LMA only and eight cases were resuscitated using LMA initially followed by ETT for long term ventilation. In the LMA groups I and III, 12 patients had LMA inserted at the first attempt and three at a second attempt. We concluded that LMA is a good alternative to ETT, although it may not protect against aspiration. We recommend it to be included in CPR chart cards and all medical doctors, nurses and paramedical staff should learn how to use it.

Anesthetic management for cesarean section in a patient with Wilson's disease.

We describe the successful management of a 28-year-old female with Wilson's disease who developed gestational pre-eclamptic hypertension (GPH) during pregnancy and who required an urgent cesarean delivery. We discuss the rationale of using magnesium sulphate prior to induction and the importance of adequate monitoring is selecting an anesthetic technique based on the pathophysiology of the disease.

Tracheal soiling with blood during intranasal surgery--comparison of two endotracheal tubes.

Sixty adult patients, ASA Classes I & II, were involved in a study to compare the effectiveness of Mallinckrodt Hi-Lo-Evac tube and Portex blue line tube in preventing soiling of the lower airways during intranasal surgery. The Hi-Lo-Evac tube with and without pack was significantly more effective than the Portex tube with pharyngeal pack (P less than 0.002) and (P less than 0.01 respectively). There was no significant difference when the Hi-Lo-Evac tube was used with or without a pack (P greater than 0.2). The more effective protection of the lower airways by the Hi-Lo-Evac tube is attributed to the facility of subglottic aspiration during surgery. It is suggested that the Hi-Lo-Evac tube could be used with safety during intranasal surgery in order to reduce postoperative morbidity associated with the use of pharyngeal pack.

Are heat stroke patients fluid depleted? Importance of monitoring central venous pressure as a simple guideline for fluid therapy.

During pilgrimage season (Hajj) in Saudi Arabia 34 patients with heat stroke (HS) were centrally cannulated to assess their state of hydration and fluid requirement during cooling period. Central venous pressure (C.V.P.) measurements indicated that most victims of heat stroke had normal C.V.P. on arrival at heat stroke centres and may not be fluid depleted. Twenty-two patients (64.7%) had normal or above normal C.V.P. Twelve patients (35.3%) had zero or below zero C.V.P. Six patients (17.6%) had above 10 cmH2O (range 10-26 cmH2O) and could have developed acute congestive heat failure and pulmonary edema if they had been transfused at the standard recommended rate of 3-4 litres of fluid during an average cooling time of 1 h as has been practiced in the heat stroke centres to date. This study also showed that heat stroke patients should not be briskly transfused because the heart may be affected by heat stroke per se and an unmonitored challenge by brisk i.v. therapy during cooling (which on its own increases preload on the heart due to peripheral vasoconstriction) can lead to acute overload problems. An average of 1 litre of normal saline or Ringer's lactate (crystalloids) was sufficient to normalize C.V.P. during the cooling period and to restore an optimal state of hydration without predisposing to congestive cardiac failure and pulmonary edema--the potential to develop disastrous adult respiratory distress syndrome and disseminated intravascular coagulopathy.

Cardiopulmonary resuscitation skills of medical professionals.

This study examined the theoretical knowledge and practical skills of different medical profession personnel and medical students in Basic Cardiac Life Support (BCLS). Two hundred twenty-four candidates who attended a BCLS course were tested in their theoretical knowledge of BCLS with 15 multiple choice questions (MCQs) as a pre-test. The same questions were included in the post-test but with a different sequence. We also evaluated each candidate during performance of single-rescuer CPR on a recording manikin, using a checklist and the recording strip from the manikin for evaluation of CPR steps and manikin performance respectively. Anesthesiologists and cardiologists demonstrated the best performance in the theoretical knowledge test followed by GPs and paramedics. In contrast, physicians, surgeons, pediatricians and medical students had comparable scores. No candidate performed all CPR steps correctly in the proper sequence. In addition, the manikin performance of all groups was poor. Nevertheless, the course significantly improved the theoretical knowledge (P less than 0.0001) and performance in both CPR steps (P less than 0.0005) and manikin performance (P less than 0.0005). The multivariate discriminant analysis identified that experience and prior CPR training influenced significantly (P less than 0.001) the degree of retention of theoretical knowledge only, but not the actual performance of basic resuscitation. It is concluded that no assumption based on previous clinical knowledge should be made for the expected CPR performance of all doctors, regardless of speciality. Formal training programs in medical schools should be considered. Our data also indicate that training is the only objective way to improve performance of all the candidates including the medical students.

Disseminated intravascular coagulopathy diagnosed by computed tomography.

A 24-year-old man was brought to casualty after a fall. He suffered from head injury and multiple fractures. On arrival he was apneic and the heart was at a standstill. Resuscitation was successful and the patient was taken to the CT room to assess the extent of his head trauma. At the end of the procedure, maintaining adequate ventilation proved to be very difficult; the blood pressure was rapidly falling and the ECG showed severe bradycardia. Asystole followed and resuscitation was unsuccessful. Postmortem CT scanning of the chest revealed that the tracheobronchial tree was flooded with blood and coagulation profile showed the picture of disseminated intravascular coagulopathy. CT may be useful in the diagnosis of some pathological conditions when autopsy is difficult to perform.