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Background Central line-associated bloodstream infections (CLABSIs) are significant healthcare-associated infections that increase morbidity, mortality, and healthcare costs. This study aims to analyze the frequency, microbiology, risk factors, and outcomes of CLABSI in an adult intensive care unit. Methods We conducted a hospital-based, prospective surveillance study in the critical care unit of a tertiary care hospital. We included patients with a central line (CL) from admission until discharge or line removal. Data collection focused on patient demographics, comorbidities, CL insertion site, and CLABSI rates. The incidence of CLABSI was calculated per 1,000 CL-days, and statistical analysis was performed using the Chi-square test. Results Of the 169 patients enrolled, 123 episodes of bloodstream infections were recorded, 56 (45.5%) of which were CLABSIs. The organisms most frequently isolated were Klebsiella pneumoniae (n = 14; 24.6%), Enterobacter cloacae complex (n = 11; 19.3%), Klebsiella species (n = 7; 12.28%), and Acinetobacter baumannii (n = 7; 12.28%). The overall CLABSI rate was 24.70 per 1,000 CL-days. No significant association was found between CLABSI and patient age, gender, or the site of CL insertion. However, a significant relationship was observed between CLABSI and the presence of comorbid conditions (p = 0.001). The study also noted a high rate of antibiotic resistance among the isolated pathogens. Conclusions Our results emphasize the need for stringent infection control measures and suggest that comorbid conditions significantly increase the risk of CLABSI. Addressing antibiotic resistance and implementing effective prevention strategies are essential for reducing the burden of CLABSIs.
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Background Continuity of personal care by the anesthesiologist is crucial for patient satisfaction. Over and above the consultation and service in the preoperative area, intraoperative care, and post-anesthesia care unit, anesthesia services frequently incorporate a pre-anesthesia evaluation clinic and a preoperative visit in the inpatient ward for their services, which helps with rapport building. However, routine post-anesthesia visits in the inpatient ward by the anesthesiologist are infrequent, causing a break in the continuity of care. The effect of such a routine post-operative visit by anesthesiologists has been tested only rarely in the Indian population. The present study aimed to evaluate the impact of a single postoperative visit by the same anesthesiologist (continuity of care) on patient satisfaction and compare it with a postoperative visit by another anesthesiologist and no postoperative visit. Methods After institutional ethical committee approval, 276 American Society of Anesthesiologists physical status (ASA PS) I and II, consenting, elective surgical inpatients older than 16 years were enrolled in a tertiary care teaching hospital from January 2015- September 2016. Consecutive patients were allocated into three groups based on the postoperative visit (i.e., group A: by the same anesthesiologist; group B: another anesthesiologist; and group C: no visit). Data related to patients' satisfaction were collected in a pretested questionnaire. Chi-Square and Analysis of Variance (ANOVA) were applied to analyze the data and compare among the groups; a p < 0.05 was considered statistically significant. Results The mean age of the entire cohort was 38.1 years, comprising 39.9% men. Demographic, socioeconomic, and educational statuses were similar in all groups (p >0.05). The percentages of patient satisfaction were 61.47%, 51.52%, and 38.5% in groups A, B, and C, respectively (p=0.0001). Satisfaction with the fulfillment of "continuity of personal care" was the highest for group A (69.35%), which was significantly higher than group B (43.69%) and group C (35.65%). Group C had the lowest fulfillment of patient expectations and was significantly less satisfied than even group B (p=0.02). Conclusion Continuity of anesthesia care with the addition of routine postoperative visits had the highest positive impact on patient satisfaction. Even a single postoperative visit by the anesthesiologist significantly increased the patients' satisfaction.
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Post-anaesthesia shivering is a common complication and has multiple deleterious effects. Sometimes multiple non-pharmacological interventions applied together may not control post-anaesthesia shivering adequately, necessitating the use of drugs in some cases. Hand warming is commonly used to warm up the body since time immemorial but its role in preventing post-anaesthesia shivering has not been evaluated. This case series describes the application of this simple and safe method of focal hand warming along with other non-pharmacological measures to suppress post-anaesthesia shivering, whereby possible use of drugs could be avoided.
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BACKGROUND: Health-care-associated infections (HAIs) cause significant morbidity and mortality globally, including in low-income and middle-income countries (LMICs). Networks of hospitals implementing standardised HAI surveillance can provide valuable data on HAI burden, and identify and monitor HAI prevention gaps. Hospitals in many LMICs use HAI case definitions developed for higher-resourced settings, which require human resources and laboratory and imaging tests that are often not available. METHODS: A network of 26 tertiary-level hospitals in India was created to implement HAI surveillance and prevention activities. Existing HAI case definitions were modified to facilitate standardised, resource-appropriate surveillance across hospitals. Hospitals identified health-care-associated bloodstream infections and urinary tract infections (UTIs) and reported clinical and microbiological data to the network for analysis. FINDINGS: 26 network hospitals reported 2622 health-care-associated bloodstream infections and 737 health-care-associated UTIs from 89 intensive care units (ICUs) between May 1, 2017, and Oct 31, 2018. Central line-associated bloodstream infection rates were highest in neonatal ICUs (>20 per 1000 central line days). Catheter-associated UTI rates were highest in paediatric medical ICUs (4·5 per 1000 urinary catheter days). Klebsiella spp (24·8%) were the most frequent organism in bloodstream infections and Candida spp (29·4%) in UTIs. Carbapenem resistance was common in Gram-negative infections, occurring in 72% of bloodstream infections and 76% of UTIs caused by Klebsiella spp, 77% of bloodstream infections and 76% of UTIs caused by Acinetobacter spp, and 64% of bloodstream infections and 72% of UTIs caused by Pseudomonas spp. INTERPRETATION: The first standardised HAI surveillance network in India has succeeded in implementing locally adapted and context-appropriate protocols consistently across hospitals and has been able to identify a large number of HAIs. Network data show high HAI and antimicrobial resistance rates in tertiary hospitals, showing the importance of implementing multimodal HAI prevention and antimicrobial resistance containment strategies. FUNDING: US Centers for Disease Control and Prevention cooperative agreement with All India Institute of Medical Sciences, New Delhi. TRANSLATION: For the Hindi translation of the abstract see Supplementary Materials section.
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Antiinfecciosos , Infección Hospitalaria , Neumonía Asociada al Ventilador , Sepsis , Infecciones Urinarias , Niño , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Humanos , Recién Nacido , Klebsiella , Neumonía Asociada al Ventilador/complicaciones , Neumonía Asociada al Ventilador/epidemiología , Neumonía Asociada al Ventilador/microbiología , Estudios Prospectivos , Centros de Atención Terciaria , Infecciones Urinarias/epidemiologíaRESUMEN
BACKGROUND AND AIM: Currently, ultrasound-guided (US-guided) internal jugular vein (IJV) cannulation is the recommended technique. However, it has a learning curve and might be unsafe in inexperienced hands. The present study aimed to compare the performance and complications with two levels of experience in performing US-guided right IJV cannulation. METHODS: With informed consent, 108 procedures were performed after random allocation into two groups based on operator experience. An operator with experience in performing 30 or more ultrasound-guided IJV cannulation was considered an expert. The rate of successful cannulation, the time needed, number of attempts, and complication rate were measured. Quantitative continuous variables were compared using the unpaired student's t-test, and the chi-square test or Fisher's-exact test was used for the comparison of qualitative variables; P-value < 0.05 was considered significant. RESULTS: The successful cannulation rates were 100% versus 94.44% in the expert and non-expert groups, respectively; (P=0.0803). The mean time for successful cannulation and the percentage of patients who required ≥ two attempts were significantly lower in the expert group (33.28 seconds and 12.96% versus 95.42 seconds and 61.12%). Although the incidence of carotid artery puncture and hematoma (7.4% and 5.56%) was higher in the non-expert group, it was not statistically different; (P=1.00). CONCLUSION: US-guided right IJV cannulation has a learning curve, and procedures as many as 30 US-guided IJV cannulation need to be observed and performed under the guidance to achieve it.
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BACKGROUND: Healthcare associated infections (HAIs) are prevalent and difficult to treat worldwide. Most HAIs can be prevented by effective implementation of Infection Prevention and Control (IPC) measures. A survey was conducted to assess the existing IPC practices across a network of Indian Hospitals using the World Health Organization designed self-assessment IPC Assessment Framework (IPCAF) tool. METHODS: This was a cross sectional observation study. Thirty-two tertiary care public and private facilities, part of the existing Indian HAI surveillance network was included. Data collected was analyzed by a central team at All India Institute of Medical Sciences, New Delhi, a tertiary care hospital of India. The WHO questionnaire tool was used to understand the capacity and efforts to implement IPC practices across the network. RESULTS: The overall median score of IPCAF across the network was 620. Based on the final IPCAF score of the facilities; 13% hospitals had basic IPC practices, 28% hospitals had intermediate and 59% hospitals had advanced IPC practices. The component multimodal strategies had the broadest range of score while the component IPC guidelines had the narrowest one. CONCLUSIONS: Quality improvement training for IPC nurses and healthcare professionals are needed to be provided to health facilities.
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Infección Hospitalaria , Control de Infecciones , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Estudios Transversales , Atención a la Salud , Instituciones de Salud , Humanos , Autoinforme , Encuestas y CuestionariosRESUMEN
INTRODUCTION: Various types of arrhythmia have been reported during cesarean section under spinal anesthesia. But the possible causative factors and the effects of arrhythmia on immediate post-delivery neonatal outcome are not well established. METHODS: This prospective observational study was conducted over a period of one year in a tertiary care hospital on women undergoing cesarean section under spinal anesthesia. The objectives of the study were to determine the incidence of arrhythmia, its types, the possible factors influencing arrhythmia, and the immediate post-delivery neonatal outcome. Data collected were analyzed using Statistical Package for the Social Sciences (SPSS) software version 21 (IBM Corp. Armonk, NY). RESULTS: In our study, the incidence of arrhythmia was 31.9% during cesarean section under spinal anesthesia; and sinus bradycardia was the most common type. Arrhythmia occurred more in women with hypotension, when maximum block height was above T4 level and dose of intrathecal hyperbaric bupivacaine was more than 2.2 mL (P value <0.05). Also, uterine manipulation led to sudden bradycardia and transient cardiac asystole in two patients which was preceded by subjective symptoms of pain and discomfort. None of the neonates required cardiopulmonary resuscitation or neonatal intensive care unit admission within an hour of birth. APGAR (Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration) scores at 1 and 5 minutes were similar in all the newborns born to mothers with or without arrhythmia. CONCLUSION: The occurrence of arrhythmia during cesarean section under spinal anesthesia, though very common, is rarely life-threatening. Keeping maximum level of block height between T4 and T6, using lower possible drug dose to provide adequate level of sensory block, prompt management of hypotension, and strict monitoring during uterine manipulation may reduce the overall incidence of arrhythmia. Intraoperative arrhythmia, however, does not adversely affect the immediate post-delivery neonatal outcome.
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Owing to COVID-19 pandemic, wearing personal protective equipment (PPE) and N95 mask inside an operation theatre has become a common practice. Subjective symptoms of suffocation, headache, dizziness, and lack of concentration while on PPE may at times become significant enough requiring oxygen therapy, removal of mask, or even doffing of PPE, which may increase the risk of being infected and at the same time compromising patient care. The reason behind such subjective symptoms may be multifactorial. We report here a 52-years-old anesthetist with a high body mass index, wearing PPE for a prolonged duration inside an operation theatre during a high-risk surgery encountered a similar episode. Being the lone anesthetist, he decided to oxygenate himself in an innovative way, thus, avoiding doffing and any undesirable event. With pandemic expanding rapidly such scenarios may be encountered often, identifying factors predicting such events and finding methods of oxygenation while wearing PPE may be extremely beneficial.
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BACKGROUND AND AIM: Nalbuphine as an adjuvant intrathecally can produce significant analgesia with minimal side effects. However, no research has been done with isobaric ropivacaine. We, therefore, in this prospective, randomised double-blind study tried to find the optimal dose of intrathecal nalbuphine with isobaric 0.75% ropivacaine for elective lower limb surgeries. MATERIALS AND METHODS: One hundred American Society of Anaesthesiologists I and II patients undergoing elective lower limb surgery were divided into four groups randomly: groups A, B, C and D, who received 0.5 mL normal saline or 0.4, 0.8 and 1.6 mg nalbuphine made up to 0.5 mL normal saline added to 22.5 mg (total volume 3.5 mL) isobaric 0.75% ropivacaine, respectively. The onset of sensory and motor block, two-segment regression time, duration of sensory and motor block, Visual Analogue Scale (VAS) and the incidence of adverse effects were compared between the groups. RESULTS: The onset of both sensory and motor blockade was faster with addition of 0.4, 0.8 and 1.6 mg of nalbuphine when compared with ropivacaine alone; however, it was not statistically significant (P > 0.05). Two-segment regression time and duration of analgesia and motor blockade were highest with 1.6 mg of nalbuphine followed by 0.8, 0.4 and plain 0.75% ropivacaine (P < 0.05). The duration of sensory blockade in all four groups was slightly more than the duration of motor blockade. VAS readings were comparable in all nalbuphine groups when compared with ropivacaine group. Haemodynamic variability among the four groups was comparable. Incidence of adverse effects was highest in the 1.6-mg group when compared with others, although it was statistically insignificant (P > 0.05). CONCLUSION: Nalbuphine can be a good alternative to other opioids as an adjuvant intrathecally to prolong postoperative analgesia with a minimal side effect profile. Addition of nalbuphine to isobaric 0.75% ropivacaine gives the added advantage of significant analgesia with early motor recovery. We infer from our study that when compared with 1.6 mg of nalbuphine, both 0.4 and 0.8 mg nalbuphine are equally good as adjuvants to isobaric 0.75% ropivacaine in elective lower limb surgeries with prolonged analgesia, a reliable block with equal efficacy but with lesser side effects.
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BACKGROUND: Sacroiliac joint dysfunctional pain has always been an enigma to the pain physician, whether it be the diagnosis or the treatment. Diagnostic blocks are the gold standard way to diagnose this condition. Radiofrequency neurotomy of the nerves supplying the sacroiliac joint has shown equivocal results due to anatomical variation. Intraarticular depo-steroid injection is a traditional approach to treating sacroiliac joint pain. For long-term pain relief, however, lesioning the sacral lateral branches may be a better approach. OBJECTIVE: This study compared the efficacy of intraarticular depo-methylprednisolone injection to that of pulsed radiofrequency ablation for sacroiliac joint pain. STUDY DESIGN: This study used a randomized, prospective design. SETTING: Thirty patients with diagnostic block-confirmed sacroiliac joint dysfunctional pain were randomly assigned to 2 groups. One group received intraarticular methylprednisolone and another group underwent pulsed radiofrequency of the L4 medial branch, the L5 dorsal rami, and the lateral sacral branches. RESULTS: Reduction in Numeric Rating Scale (NRS) for pain at 1 month post-procedure remained similar in Group A, while in Group B few patients reported a further decrease in the NRS score (3.333 ± 0.4880 and 2.933 ± 0.5936, respectively). At 3 months post-procedure, the NRS score began to rise in most patients in group A, while in Group B, the NRS score remained the same since the last visit (4.400 ± 0.9856 and 3.067 ± 0.8837, respectively). At 6 months post-procedure, the NRS score began to rise further in most patients in group A. In Group B, the NRS score remained the same in most of the patients since the last visit (5.400 ± 1.549 and 3.200 ± 1.207). There was a marked difference between the 2 groups in Oswestry Disability Index (ODI) scores at 3 months post-procedure (Group A, 12.133 ± 4.486 vs Group B, 9.133 ± 3.523) and at 6 months post-procedure there was a significant (P = 0.0017) difference in ODI scores between Group A and Group B (13.067 ± 4.284 and 8.000 ± 3.703, respectively). Global Perceived Effect (GPE) was assessed in both groups at 3 months post-procedure Only 33.3% (Confidence Interval (CI) of 11.8- 61.6 ) of patients in Group A had positive GPE responses whereas in Group B, 86.67% (CI of 59.5- 98.3 ) of patients had positive GPE responses. At 6 months post-procedure, the proportion of patients with positive GPE declined further in Group A, while in Group B, positive GPE responses remained the same (20% with a CI of 4.30- 48.10 and 86.67% with a CI of 59.5- 98.3, respectively ). LIMITATIONS: Small sample size. CONCLUSION: This comparative study shows that pulsed radiofrequency denervation of the L4 and L5 primary dorsal rami and S1-3 lateral branches provide significant pain relief and functional improvement in patients with sacroiliac joint pain. KEY WORDS: Low back pain, sacroiliac joint dysfunctional pain, radiofrequency, intraarticular injection.
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Antiinflamatorios/uso terapéutico , Dolor de la Región Lumbar/terapia , Metilprednisolona/uso terapéutico , Manejo del Dolor/métodos , Tratamiento de Radiofrecuencia Pulsada/métodos , Adulto , Artralgia/terapia , Preparaciones de Acción Retardada/uso terapéutico , Desnervación/métodos , Femenino , Humanos , Inyecciones Intraarticulares/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Articulación Sacroiliaca/efectos de los fármacosRESUMEN
PURPOSE: Delirium is a disorder of decreased ability to focus, sustain or shift attention, change in cognition and or perception. The main objective was to evaluate the diagnostic accuracy of Confusion Assessment Method for the ICU (CAM-ICU) and Intensive Care Delirium Screening Checklist (ICDSC) among the nursing and medical staff in a multidisciplinary ICU. METHODS AND MATERIAL: Three hundred ten verbally communicating and non-communicating patients (mean age in years 47.9, standard deviation [SD] 14.5, mean Acute Physiology and Chronic Health Evaluation II score 13.8, SD 6.4) were assessed by a psychiatrist, nurse and intensivist for delirium. Inter-rater agreement was measured by Cohen's kappa coefficient. Sensitivity, specificity, predictive values, likelihood ratios and diagnostic odds ratio (DOR) were calculated. RESULTS: CAM-ICU showed higher sensitivity and DOR (84%, 86.1) compared to ICDSC (78%, 36.9). ICDSC had specificity and positive predictive value (94.5%, 92%) equal to that of CAM-ICU. For both the assessment methods (CAM-ICU and ICDSC), DORs for intensivists (120.5, 53.0) were relatively higher than nurses (67.0, 27.0). CONCLUSIONS: In our mixed ICU population, CAM-ICU remained more sensitive than ICDSC. Though sensitivity and DOR were higher for medical staff, other diagnostic parameters were similar for both medical and nursing staff.
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Lista de Verificación , Cuidados Críticos/métodos , Delirio/diagnóstico , Técnicas de Diagnóstico Neurológico , Tamizaje Masivo/métodos , Adulto , Anciano , Femenino , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Complicaciones Posoperatorias/diagnóstico , Reproducibilidad de los ResultadosRESUMEN
CONTEXT: The primary goal of septic shock management is optimization of organ perfusion, often at the risk of overloading the interstitium and causing pulmonary edema. The conventionally used end points of resuscitation do not generally include volumetric parameters such as extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). AIMS: This study aimed to assess the prognostic value of EVLWI and PVPI by calculating their correlation with the severity of lung injury. SETTINGS AND DESIGN: This prospective observational study included twenty mechanically ventilated critically ill patients with Acute Physiology and Chronic Health Evaluation score (APACHE II) >20. SUBJECTS AND METHODS: EVLWI and PVPI were measured using transpulmonary thermodilution, and simultaneously, PaO2:FiO2 ratio, alveolar-arterial gradient of oxygen (AaDO2), and chest radiograph scores from two radiologists were obtained. STATISTICAL ANALYSIS: The correlation of EVLWI and PVPI with chest radiograph scores, PaO2:FiO2 ratio, and AaDO2 were calculated. The inter-observer agreement between the two radiologists was tested using kappa test. RESULTS: EVLWI and PVPI correlated modestly with PaO2:FiO2 (r = -0.32, P = 0.0004; r = -0.39, P = 0.0001). There was a better correlation of EVLWI and PVPI with PaO2:FiO2 ratio (r = -0.71, P < 0.0001; r = -0.58, P = 0.0001) in the acute respiratory distress syndrome (ARDS) subgroup. The EVLWI values correlated significantly with corresponding chest radiograph scores (r = 0.71, P < 0.0001 for observer 1 and r = 0.68, P < 0.0001 for observer 2). CONCLUSIONS: EVLWI and PVPI may have a prognostic significance in the assessment of lung injury in septic shock patients with ARDS. Further research is required to reveal the usefulness of EVLWI as an end point of fluid resuscitation in the management of septic shock with ARDS.
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INTRODUCTION: Hypocalcaemia is very much prevalent in critically ill patients yet very less is known about its association with severity of illness. Acute Physiology and Chronic Health Evaluation (APACHE) and Sequential Organ Failure Assessment (SOFA) are two commonly used and validated scoring tool used to assess the severity of illness in critically ill patients. AIM: To analyze the relation of on admission hypocalcaemia with severity of illness as measured by APACHE-II and SOFA scores. MATERIALS AND METHODS: After institute approval, 111 patients admitted during May to June 2016 were evaluated. Age, sex, on admission, ionized calcium (iCa0) levels, first day APACHE-II and SOFA scores were collected. Data were then divided in different classes based on iCa0 levels (i.e., normocalcaemic, mild, moderate and severe hypocalcaemic), APACHE-II and SOFA scores and their relationship was assessed using INSTAT software (GraphPad Software, Inc, La Zolla, CA, USA) with appropriate statistical tests. RESULTS: Seventy eight (70.27%) patients were having hypocalcaemia on admission (<1.15 mmol/L). The mean APACHE-II score of normocalcaemic patients were significantly (p<0.05) lower as compared to moderate and severe hypocalcaemic patients (15.57±6.85 versus 21.72±6.37 and 15.57±6.85 versus 22.34±7.53, respectively). The mean iCa0 level in patients with APACHE-II > 20 were significantly lower than patients with APACHE-II < 9 (0.88±0.26 versus 1.09±0.24, p <0.05) but the mean iCa0 level in patients with SOFA > 9 were not significantly lower than patients with SOFA < 4 (0.99±0.41 versus 1.04±0.23, p > 0.05). The relative risk of on admission hypocalcaemia across increasing illness severity was also not statistically significant. Both relative risk of mortality and length of ICU stay were higher in on admission moderate hypocalcaemic patients as compared to normocalcaemic but the difference was not statistically significant. CONCLUSION: On admission, hypocalcaemia has inconsistent correlation with increasing illness severity in adult intensive care patients. iCa0 of 0.81-0.90 mmol/L appears to have maximum deleterious effect with regard to mortality and length of ICU stay.
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INTRODUCTION: Bloodstream infection (BSI) is a leading cause of mortality in critically ill patients. The mortality directly attributable to BSI has been estimated to be around 16% and 40% in general hospital population and Intensive Care Unit (ICU) population, respectively. The detection rate of these infections increases with the number of blood samples obtained for culture. The newer continuous monitoring automated blood culture systems with enhanced culture media show increased yield and sensitivity. Hence, we aimed at studying the role of single and multiple blood specimens from different sites at the same time in the outcome of automated blood culture system. MATERIALS AND METHODS AND RESULTS: A total of 1054 blood culture sets were analyzed over 1 year, the sensitivity of one, two, and three samples in a set was found to be 85.67%, 96.59%, and 100%, respectively, which showed a statistically significant difference (P < 0.0001). Similar findings were seen in few more studies, however, among individual organisms in contrast to other studies, the isolation rates of Gram-positive bacteria were less than that of Gram-negative Bacilli with one (or first) sample in a blood culture set. In our study, despite using BacT/ALERT three-dimensional continuous culture monitoring system with FAN plus culture bottles, 15% of positive cultures would have been missed if only a single sample was collected in a blood culture set. CONCLUSION: The variables like the volume of blood and number of samples collected from different sites still play a major role in the outcome of these automated blood culture systems.
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BACKGROUND AND AIMS: Pre-operative investigations are often required to supplement information for risk stratification and assessing reserve for undergoing surgery. Although there are evidence-based recommendations for which investigations should be done, clinical practice varies. The present study aimed to assess the pre-operative investigations and referral practices and compare it with the standard guidelines. METHODS: The present observational study was carried out during 2014-appen2015 in a teaching institute after the approval from Institute Ethical Committee. A designated anaesthesiologist collected data from the completed pre-anaesthetic check-up (PAC) sheets. Investigations already done, asked by anaesthesiologists as well as referral services sought were noted and compared with an adapted master table prepared from standard recommendations and guidelines. Data were expressed in frequencies, percentage and statistically analysed using INSTAT software (GraphPad Prism software Inc., La Zolla, USA). RESULTS: Seventy-five out of 352 patients (42.67% male, 57.33% female; American Society of Anesthesiologists physical status I to III) were included in this study. Nearly, all patients attended PAC with at least 5 investigations done. Of them, 89.33% were subjected to at least one unnecessary investigation and 91.67% of the referral services were not required which lead to 3.5 ( SD ±1.64) days loss. Anaesthesiologist-ordered testing was more focused than surgeons. CONCLUSION: More than two-third of pre-operative investigations and referral services are unnecessary. Anaesthesiologists are relatively more rational in ordering pre-operative tests yet; a lot can be done to rationalise the practice as well as reducing healthcare cost.
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Scrub typhus and malaria can involve multiple organ systems and are notoriously known for varied presentations. However, clinical malaria or scrub typhus is unusual without fever. On the other hand, altered sensorium with or without fever, dehydration, hemorrhage and hemolysis may lead to low blood pressure. Presence of toxic granules and elevated band forms in such patients can even mimic sepsis. When such a patient is in the peripartum period, it creates a strong clinical dilemma for the physician especially in unbooked obstetric cases. We present such a case where a 26-year-old unbooked female presented on second postpartum day with severe anemia, altered sensorium, difficulty in breathing along with jaundice and gum bleeding without history of fever. Rapid diagnostic test for malaria was negative and no eschar was seen. These parameters suggested a diagnosis of HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet) syndrome with or without puerperal sepsis. Subsequently she was diagnosed as having asymptomatic malaria and scrub typhus and responded to the treatment of it. The biochemical changes suggestive of HELLP syndrome also subsided. We present this case to emphasize the fact that mere absence of fever and eschar does not rule out scrub typhus. It should also be considered as a differential diagnosis in patients with symptoms and signs suggesting HELLP syndrome. Asymptomatic malaria can complicate case scenario towards puerperal sepsis by giving false toxic granules and band form in such situations.
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BACKGROUND: Basic life support (BLS) is an integral part of emergency medical care. Studies have shown poor knowledge of it among health care providers who are usually taught BLS by lecture-based teachings in classes. OBJECTIVES: This study is designed to assess the effectiveness of class lecture versus workshop-based teaching of BLS on acquiring the practice skills on mannequin. METHODS: After ethical approval and informed consent from the participants, the present study was conducted among the health care providers. Participants were grouped in lecture-based class teaching and workshop-based teaching. They were then asked to practice BLS on mannequin (Resusci Anne with QCPR) and evaluated as per performance parameters based on American Heart Association BLS. Statistical analyses are done by Fisher's exact t-test using GraphPad INSTAT software and P < 0.05 is taken as significant. RESULTS: There were 55 participants in lecture-based teaching and 50 in workshop-based teaching group. There is no statistical difference in recognition of arrest, checking pulse, and starting chest compression (P > 0.05). Though more than 83% of lecture-based teaching group has started chest compression as compared 96% of workshop group; only 49% of the participants of lecture-based group performed quality chest compression as compared to 82% of other group (P = 0.0005). The workshop group also performed better bag mask ventilation and defibrillation (P < 0.0001). CONCLUSION: Workshop-based BLS teaching is more effective and lecture-based class teaching better is replaced in medical education curriculum.
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INTRODUCTION: Low Cardiac Output Syndrome (LCOS) following Cardiopulmonary Bypass (CPB) is common and associated with increased mortality. Maintenance of adequate cardiac output is one of the primary objectives in management of such patients. AIM: To compare Levosimendan, Milrinone and Dobutamine for the treatment of LCOS after CPB in patients who underwent valve replacement surgeries. MATERIALS AND METHODS: Sixty eligible patients meeting LCOS were allocated into three treatment groups: Group A-Levosimendan (loading dose 10µg/kg over 10 minutes, followed by 0.1µg/kg/min); Group B-Milrinone (loading dose 50 mcg/kg over 10 minutes followed by 0.5mcg/kg/min) and Group C-Dobutamine @ 5µg/kg/min to achieve target cardiac index (CI) of > 2.5 L/min/m2. In case of failure, other drugs were added as required. Hemodynamic parameters were monitored using EV1000TM clinical platform till 30 minutes post CPB. INSTAT software was used for statistics and p<0.05 was considered significant. RESULTS: The mean±standard deviation of time taken by Dobutamine, Levosimendan and Milrinone to bring the CI to target were 11.1±8.79, 11.3±6.34 and 16.62±9.33 minutes respectively (p=0.064). Levosimendan was equally effective in increasing and maintaining adequate CI as compared to Dobutamine (p>0.05). Levosimendan and Milrinone increased MAP (Mean Arterial Pressure) equally while Dobutamine was more effective as compared to both Levosimendan and Milrinone 20th minute onwards (p<0.01). Milrinone was less effective in increasing the stroke volume as compared to Dobutamine and Levosimendan while Dobutamine and Levosimendan were equally effective. There was no difference in the HR (Heart Rate) achieved with all these three drugs. CONCLUSION: Levosimendan is equally effective to Dobutamine and better than Milrinone for the treatment of LCOS following CPB in patients undergoing valve replacement surgeries.