Critical Care Department Research Articles

Myocardial injury and anaemia in patients undergoing surgery for fractured neck of femur: An observational study.

Myocardial injury and anaemia in patients undergoing surgery for fractured neck of femur: An observational study.

Unintentional Symptom Intensification by Doctors.

Physicians at times are confronted with patients who present with vague yet disabling, nonprogressive symptoms for which they can offer no concrete medical explanation despite extensive evaluation. Many individuals who present with abdominal complaints, musculoskeletal pain, headaches, fatigue, dizziness, and other symptoms and/or their families believe that an undiscovered anatomic or biochemical aberration explains their symptoms despite having been informed that the symptoms may represent a “functional disorder.”1 They have difficulty believing that relatively common disorders such as functional abdominal pain,2 fibromyalgia,3 and chronic daily headache can cause the incapacitating symptoms that they or their children are experiencing. Their belief that a more specific “organic” explanation exists is rooted in the medical model, which implies that there is a specific cause for most symptoms that, when identified, will offer a path to cure.4 The faith in this conviction is reinforced by reports of miraculous cures in the press, in medical dramas on television, and by material on the Internet that allows patients to search for uncurated information that might explain their symptoms and communicate with others confronting similar issues. Pediatricians may be particularly vulnerable to experiencing this phenomenon because of intense parental desire for a diagnosis that captures the symptoms that their child is experiencing.5 As a result, many individuals believe that the solution to their or their child’s suffering exists around the next investigative corner, and they bring this expectation to each physician encounter. Unfortunately, at the end of these visits, if no organic diagnosis emerges, patients are often disappointed and unsatisfied and physicians are often frustrated. We perceive that physicians generally tend to fall into 1 of … Address correspondence to Neil L. Schechter, MD, Pain Treatment Service, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: neil.schechter{at}childrens.harvard.edu

A comparative study of hemodynamic changes and adverse effects of intrathecal bupivacaine with fentanyl and intrathecal bupivacaine with clonidine in infra-umbilical abdominal and lower limb surgery

Background: Adjuvants prolong the action of intrathecal local anesthetic agents. They have shown to have significant analgesic effects in the postoperative period much after the regression of the sensory and motor blockade. Our objective of the current study was to compared the hemodynamic profile and adverse effects (nausea, pruritus, sedation and respiratory depression) in two groups of adult patients undergoing infra-umbilical and lower limb surgery under spinal anaesthesia using either intrathecal clonidine or intrathecal fentanyl as an adjuvant to intrathecal bupivacaine (0.5% heavy).Methods: This randomized, prospective and observational study was undertaken in the Department of Anaesthesiology and Critical Care, 5 Airforce Hospital, Kanpur from the period of January 2014 to February 2016 on 120 patients fulfilling the inclusion criteria. Study patients were randomly allocated to the two groups Group I: Cases who received intrathecal 0.5% heavy bupivacaine (2.5 ml) + fentanyl (50 mcg/ml) (0.5 ml) (n=60 patients) and Group II: cases who received intrathecal 0.5% heavy bupivacaine (2.5 ml) + clonidine (60 mcg/ml) (0.5 ml) (n=60 patients).Results: Mean age of patients in Group I and Group II was 42.60±5.93 and 42.03±7.16 years, respectively. Mean BMI of patients in Group I and Group II was 22.0±1.92 and 21.54±2.14 kg/m2, respectively. Comparison of baseline hemodynamic parameters (heart rate (bpm), mean arterial pressure (mmhg), respiratory rate (/min) and oxygen saturation (%) did not show a significant difference between two groups.Conclusions: With respect to the side effects like nausea and pruritus, these are significantly more in fentanyl group as compared to clonidine group.

Integrating a pharmacist into an anaesthesiology and critical care department: Is this worthwhile?

Background Operating rooms and Intensive Care Units are places where an optimal management of drugs and medical devices is required. Objective To evaluate the impact of a dedicated pharmacist in an academic Anaesthesiology and Critical Care Department. Setting This study was conducted in the Anaesthesiology and Critical Care Department of Grenoble University Hospital. Method Between November 2013 and June 2017, the drug-related problems occurring in three Intensive Care Units and their corrections by a full-time clinical pharmacist were analyzed using a structured order review instrument. Pharmaceutical costs in the Anaesthesiology and Critical Care Department were analyzed over a 7year period (2010-2016), during which automated dispensing systems and recurrent meetings to review indications of medications and medical devices were implemented in thedepartment. Main outcome measure Analysis of two issues: correcting drug-related problems and containing pharmaceutical costs. Results A total of 324 drug-related problems were identified. The most frequent problem concerned anti-infective agents (45%), and this was mainly due to the over-dosage of drugs (30%). Dosage adjustments were the most frequent interventions performed by the pharmacist (43%). Over the 7year period, pharmaceutical costs decreased by 9% (€365,469), while the care activity of the department increased by 55% (+ 12,022 surgical procedures and + 1424 admissions in the ICU). Conclusion Integrating a pharmacist into the Anaesthesiology and Critical Care Department was associated with interventions to correct drug-related problems and containing pharmaceutical costs. Pharmacists should play a central role in such medical environments, to optimize the use of drugs and medical devices.

Improving Transport Safety by Limiting Driver Duty Hours Utilizing Simulation to Optimize Team Schedules

Creating and sustaining a safe transport environment is crucial to the medical transport industry. Fatigue is a well-described safety risk for pilots and commercial drivers. The aviation industry has developed strict guidelines to reduce such risks. Currently, similar guidelines do not apply to EMS drivers. To improve safety we applied the same commercial truck driver duty hour limits to EMS drivers. To minimize the impact this had on our team availability we developed a computer-based simulation to optimize our team schedules. The Nationwide Childrens Hospital Critical Care department implemented a plan/do/study/act (PDSA) cycle to address policy and process changes to decrease driver duty hours to 14 hours. We first implemented a policy for drivers to decline trips that would put them over their 14-hour duty limit. We then provided guidelines to standardize the decision making process. We worked with a research team from Ohio University to assist in addressing scheduling needs. The research team designed a simulation model to represent the volume, modes, origins, and destinations of our historic critical care transport data. We decreased the number of trips that exceeded the driver duty limits from six in 2017 to zero in 2018 after implementing the new policy and tools. The simulation data many schedule combinations to consider. Some of these schedule combinations were not during 'normal working hours'. Therefore, we selected the top five scheduling options that maximized team performance and were not drastically different from our current day/night schedule. We looked at scheduling drivers separately from team members and there was no measurable improvement so we did not pursue this scheduling option further. Safety must always be our top priority in transport for our patients and crew. Implementing a driver duty hour policy was an important step in address safety issues related to driver fatigue when the risk is highest at the end of a long shift. Implementing a simulation tool allowed us to test scheduling combinations that would allow us to minimize times our team would be required to work over there expected shift and maximize the availability of our team.

Effects of magnesium sulphate on intraoperative neuromuscular blocking agent requirement: A prospective randomized double blind placebo controlled study

Effects of magnesium sulphate on intraoperative neuromuscular blocking agent requirement: A prospective randomized double blind placebo controlled study - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2019.068, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Angiographically Based Direct Implantation of the Bioresorbable Vascular Scaffold in Non-ST Segment Elevation Acute Coronary Syndrome: Feasibility and Outcome.

BACKGROUND:Direct implantation of metallic drug-eluting stents is recommended for lesions with high thrombotic burden; however, this can’t be applied to bioresorbable scaffold for which adequate lesion preparation is recommended.AIM:We aimed at assessing the feasibility and safety of direct scaffold implantation based only on angiographic assessment in patients presented with non-ST segment elevation acute coronary syndrome.METHODS:The study was a retrospective two-centre study conducted over patients diagnosed with NSTE-ACS presented to cardiology department at Juan Ramon Hospital, Spain and critical care department, Cairo University in the period between February 2016 to May 2017. We included patients for whom we depend only on angiographic assessment for decision making whether to directly implant the scaffold or predilate the lesion and we excluded patients for whom intracoronary imaging was used at the index procedure either for pre or post-implantation. The primary outcome of interest was the device-oriented composite endpoints (DOCE) including cardiac death, and MI attributed to the target vessel and TLR. The secondary endpoints were the broader patient-oriented composite outcome (POCE) and scaffold/stent thrombosis. POCE includes all-cause mortality, any MI and any revascularisation (including TLR, TVR and revascularisation of non- target vessel)RESULTS:Among 46 patients with NSTE-ACS treated with BVS, we did direct implantation in 20 patients (group A), and we used pre dilatation in 26 patients (group B). The two groups have similar demographics and clinical criteria. Procedural success was obtained in all study population. Mean follow up duration was 12 months. We have total of 10% device-oriented composite endpoints in group A versus 15% in group B (p-value = 0.684). We didn’t document any cardiac death in both groups. In group B we had one (3.8%) non-fatal MI while there was no MI in group A (P-value = 1). In group A we had 2 cases (10%) of TLR while in group B there were 3 cases (11.5%) TLR (P-value = 1). We have two cases (7.7%) of TVR in group B and one in group A p-value = 1. All cases were planned staged PCI. Scaffold thrombosis occurred in one case in group A (5%) and two cases in group B (7.7%) p-value = 1.CONCLUSION:With proper lesion selection, direct BVS implantation in all-comers NSTE-ACS patients is feasible and safe even without the aid of intracoronary imaging.

Transvenous Lead Extraction of Cardiac Implantable Electronic Devices Indications, Complications and Outcome: An Egyptian Two Years' Experience.

BACKGROUND:The growing needs to extract cardiovascular implantable electronic devices warrants the need to improve the outcome and prevent complications.AIM:This study aims to analyse the findings and identify factors associated with complications of Percutaneous Transvenous Lead Extraction in the Critical Care Department, Cairo University.METHODS:We studied 52 candidates for Percutaneous Transvenous Lead extraction of a Permanent Pace Maker (PPM) regarding extraction indications, comorbidities, device type, complications and outcome. Extraction was first attempted by simple manual traction using regular non-locking stylet and if failed, locking stylet, and evolution dilator sheath were used.RESULTS:We extracted 110 leads with a mean lead age of 4.67 ± 3.6 years. The most common extraction indication was an infection (71.15%). Indications correlated significantly with comorbidities (p = 0.024), the most common being Diabetes Mellitus (40.38%). Simple traction was successful in 31 % of the leads, while 69% were extracted using locking stylet and evolution dilator sheath. The method of lead extraction correlated significantly with lead age (P ≤ 0.001). Complications were significantly higher with extraction by evolution dilator sheaths than by simple traction (P = 0.003) and in older patients (P = 0.008). Complications also correlated significantly with extractions indications (p = 0.012), type of PPM (P = 0.037), number of extracted leads (P = 0.041), and lead age (p= 0.011).CONCLUSION:Among the studied variables, extraction indications particularly infection, was the only preventable factor significantly associated with complications. While focusing on preventable factors, improving, implantation and extraction techniques should also be addressed.

Effectiveness of Lung Ultrasound in Comparison with Chest X-Ray in Diagnosis of Lung Consolidation.

BACKGROUND:Lung ultrasound (US) is an available and inexpensive tool for the diagnosis of community-acquired pneumonia (CAP); it which has no hazards of radiation and can be easily used.AIM:To evaluate the efficacy of lung ultrasound in the diagnosis and follow-up of CAP.PATIENTS AND METHODS:100 patients aged from 40 to 63 years with a mean age of 52.3 ± 10 years admitted to the Critical Care Department, Cairo University with pictures of CAP. Lung US was performed for all patients initially, then a plain chest X-ray (CXR) was performed. Another lung ultrasound was performed on the 10th day after admission.RESULTS:Initial chest X-ray was correlated with the initial chest ultrasound examination in CAP diagnosis (R-value = 0.629, P < 0.001). Cohen’s κ was run to determine if there is an agreement between the findings of the initial chest X-ray findings and those of the initial chest ultrasound in CAP diagnosis. A moderate agreement was found where κ = .567 (95% CI, 0.422 to 0.712) and P < 0.001. Upon initial examination, the CXR diagnosed CAP in 48.0% of patients, while lung US diagnosed the disease in 70% of patients. Moreover, lung US was more sensitive than CXR (P-value < 0.001). Compared to the accuracy of computed tomography (CT) chest (100%) which is the gold standard for CAP diagnosis, the accuracy of lung US was 95.0%, while the accuracy of CXR was 81.0%.CONCLUSION:This study proved the effectiveness of lung ultrasound in CAP diagnosis.

The Other Impacts of Infectious Diseases: Socio-Cultural Roles Beyond the Scene

Ahed J Alkhatib1,2* Author Affiliations 1Department of Legal Medicine, Toxicology of Forensic Science and Toxicology, School of Medicine, Jordan Jordan 2International Mariinskaya Academy, department of medicine and critical care, department of philosophy, Academician secretary of department of Sociology Received: July 08, 2019 | Published: July 15, 2019 Corresponding author: Ahed J Alkhatiib, Department of Legal Medicine, Critical care and Philosophy, Toxicology of Forensic Science and Toxicology, School of Medicine, Jordan University of Science and Technology, Jordan DOI: 10.26717/BJSTR.2019.19.003335 Also View In:

Feasibility of Routine Data Collection on Intensive Care Unit Performance and Activity in Resource Limited Settings

Background: Routine collection and analysis of data allows a critical care department to highlight the outcomes of the interventions done and to identify the grounds for improvement. Data on characteristic and outcomes of patients admitted in intensive care units (ICUs) are lacking. Methods: A software (ICU e-monitoring®) was designed to enter for each patient demographic data, SAPS3 on admission, Nine Equivalent Manpower Use Score, presence of medical devices and episodes of hospital acquired infections. We report data collected during 2014 with comparison to data collected with the same methodology in 2008 [1]. Objective: To determine the standardized mortality ratio, the mean length of ICU stay, mean length of mechanical ventilation and ICU acquired infection incidence rate. Study design: Descriptive Place of study: Medical ICU, Pakistan Institute of Medical Sciences Islamabad Results: A total of 196 admissions were recorded during the year 2014 vs 354 in 2008. 47.2% were males and 52.8% were females. Mean age was 32.1 years ± 15.3 SD (37.7 ± 18.9 SD in 2008). A total of 65 (33%) deaths were recorded during the year and standardized mortality ratio was found to be 0.71 vs 1.09 in 2008. Mean Length of stay was 15.9 Days ± 12.9 SD (9.3 days ± 8.9 in 2008) and mean duration of mechanical ventilation was found to be 12.04 Days (8.7 in 2008). Overall ventilator associated pneumonia (VAP) rate was 42.3 cases per 1000 ventilator days. Rate of Catheter Related Blood Stream Infections (CRBSI) was found to be 17.2 cases per 1000 CVC days. Conclusion: Major changes in our patient population characteristics were seen between 2008 and 2013: number of patients and standardized mortality was decreased while incidence of VAP and CRBSI was increased. It is possible to collect meaningful data on ICU performance and activity in resource limited settings.

Postoperative Critical Care for Adult Cardiac Surgical Patients

Cardiac operations represent one of the most common categories of surgery in developed countries with an annual cost in excess of $20 billion in the United States alone. Cardiac surgery is continuously evolving and modern practice has come to include minimally invasive, hybrid, and transcatheter techniques with the patient managed by “the heart team.” An increasing age and medical complexity of patients considered for cardiac surgical procedures mean that the critical care management needs to adapt to meet increasingly broad and elaborate needs. The second edition of Postoperative Critical Care for Adult Cardiac Surgical Patients remains edited by Dr Dabbagh, cardiac anesthetist, and Drs Esmailian and Aranki, both cardiac surgeons. Together they form an extensive body of professional expertise in all aspects of care of the adult cardiac surgical patient. They have supervised 26 chapter contributors representing anesthetic, critical care, and surgical departments mainly in Iran and the United States with a few Italian institutions represented as well. The book has an ambitious scope with the aim to cover all perioperative aspects of the cardiac surgical patient in 22 chapters totaling 670 pages with 60 tables and 97 illustrations, the majority in color. The format is conducive to a general discussion with a few aspects covered more in depth. All chapters are informative albeit some provide more guidance than others. The chapter of hemodynamic monitoring is detailed and includes an up-to-date overview of cardiac output monitors. A short final paragraph explains that transesophageal echocardiography is beyond the scope of this book and the reader is referred to other specialized resources. The chapter on postoperative coagulation and management of bleeding provides an excellent summary of point-of-care testing of coagulation in the intensive care unit with succinct presentations of both thromboelastography and rotational thromboelastometry. Interpretation and suggestions for actions based on results using both devices are presented and clearly summarized in table format. All relevant anticoagulants in current clinical practice and guidelines for their reversal are nicely presented. The chapter on “Postoperative Safety in Adult Cardiac Surgery Intensive Care Unit” includes a useful section on handoff protocols and also covers team huddles and team performance. In particular, the example multidisciplinary simulation scenario demonstrates the approach to building and improving teamwork along all facets of perioperative care, with a natural emphasis on postoperative complications. The chapter on cardiac anatomy is overly basic and lacking in terms of functional aspects and clinical implications. The chapter on cardiac physiology to some extent suffers from the same shortcomings and aspects of regulation of blood flow would seem to warrant a more comprehensive consideration. Some readers will surely be surprised that no references are made to the state-of-the-art research performed by Arthur Guyton. The pharmacology chapter provides a clinically orientated overview of most drugs likely to be encountered in a cardiac, or for that sake general, intensive care unit, while an approach of listing rather than categorizing by postoperative scenarios renders the text somewhat insipid. The chapter devoted to mechanical circulatory support includes rather extensive pharmacological and physiological considerations that are already covered in other chapters. This sidetracks the main theme of the text, in particular for the modality of venoarterial extracorporeal membrane oxygenation that has most relevance to cardiac intensive care practitioners. The chapter on renal complications focuses on basic principles, while renal replacement therapy is covered on less than 1 page. This appears cursory given the significance of dialysis-dependent renal failure on long-term clinical outcomes. Unfortunately, the presentation is at times distracted by a below-par English style and grammar that should have been addressed in a second revision. There is also a tendency for repetition and overlap between chapters, and a more effective use of cross-referencing would have been useful to the reader. An eBook edition is available but was not accessed for this review. The book navigates difficult waters between a preparatory text and a complete reference textbook. Those with some experience of general intensive care wanting to explore cardiac intensive care will likely find the book rewarding, while it is arguably a bit unwieldy to use as an introductory text. The fellow or specialist colleague with experience in a cardiac intensive care unit might find the text lacking in detail and depth compared to textbooks of cardiac surgery but still useful as a source for refreshing clinical knowledge. We recommend the advanced trainee or junior consultant looking for 1 manageable volume to cover the field to buy the book. Anders Aneman, MD, PhD, FCICMWilliam O’Regan, MD, FCICM, FANZCADepartment of Intensive CareLiverpool Hospital, South Western Sydney Local Health DistrictMacquarie University HospitalSydney, Australia[email protected]

Accidental removal of devices in intensive care unit: An eight-year observational study

BackgroundIn the intensive care unit, invasive devices can be accidentally removed by the patient or by the operators, increasing workload, staff stress level and hospitalisation costs. Objective: to know the incidence of accidental removal of devices in critical patients, to identify their cause, when they occur and if they are repositioned. MethodsRetrospective observational study carried out in an academic, tertiary-level critical care department composed of three intensive care units. All adult patients recovered between 2011 and 2018 were enrolled. We calculated rates per 1000 device-years. ResultsIn the study period 10514 patients (194372 device-days) were admitted to the intensive care units and the number of reported accidental removal of devices was 451, corresponding to a rate of 2.3 episodes per 1000 device-days (95% confidence interval: 2.1–2-5). The overall rates of accidental removals were as follows: gastric tubes 10.2 (n = 270), intracranial devices 3.9 (n = 9), endotracheal tubes 2.4 (n = 27), central venous catheters and arterial catheters 1.5 (n = 92), peripheral intravenous catheters 1.2 (n = 25), surgical drains 0.5 (n = 15), urinary catheters 0.4 (n = 11), Extra Corporeal Membrane Oxygenation cannulas 0.4 (n = 1), tracheostomy cannulas 0.1 (n = 1). ConclusionCompared to the literature, this study shows fewer incidents of accidental removal of devices. The number of accidental removals could be an indicator of the quality and safety of the care.

To Whom Thrombus Aspiration May Concern?

BACKGROUND:Thrombus aspiration for ST-segment elevation myocardial infarction (STEMI) may improve myocardial perfusion. However, these favourable results called into a question by data indicating not only a lack of efficacy but a risk of potentially deleterious complications.AIM:To assess the effect of thrombus aspiration during the primary percutaneous coronary intervention (PPCI) on procedural angiographic results, stent characteristics, and major adverse cardiac and cerebrovascular events (MACCE).METHODS:All consecutive STEMI patients candidate for PPCI and admitted to Critical Care Department, Cairo University hospitals, managed either by thrombectomy before primary PCI (if thrombus score ≥ 3) or conventional PPCI, Six hundred seven subjects were enrolled in the study divided into Group with thrombectomy before PPCI (107 subjects, 18%), and group with Conventional PCI (500 subjects, 82%). ST-segment resolution, peak CK-MB, TIMI score, thrombus score, and MBG were assessed; stent number, diameter, length and stented segment were reported and follow up MACCE was reported (in hospital and 1-year post-intervention).RESULTS:Mean values for peak CKMB were less in thrombectomy group (228 ± 174 I/U vs 269 ± 186 I/U, p = 0.04), ST segment resolution ≥ 70% occurred in {63 subjects (58.9%) vs 233 (46.6%), p = 0.001} in thrombectomy vs conventional group respectively. TIMI score pre procedure was zero in (102 subjects (95%) vs 402 (80.4%), p = 0.001), while TIMI III post procedure was reported in (100 subjects (93.4%) vs 437 (87%), p = 0.06), MBG mean values were (2.4 ± 0.6 vs 2.0 ± 1, p = 0.001), thrombus score was higher in thrombectomy group (4.6 ± 0.4 vs 0.8 ± 1.7, p = 0.001) in thrombectomy vs conventional group respectively. Direct stenting was { 34 patients (31%) vs 102 patients (20%), p = 0.05}, mean stent diameter (2.7 ± 1.3 mm vs 3.5 ± 1.3 mm, p = 0.3), mean stent length was (19.9 mm ± 10 versus 22.7 mm ± 8 in p 0.01). mean stent number was (1.0 ± 0.5 vs 1.2 ± 0.6, p = 0.001), mean stented segment was (22.5 ± 13.5 vs 28.5 ± 15.2 mm, p = 0.001) in thrombectomy vs conventional group respectively. MACCE in hospital were reported in {9 subjects (8.4%) vs 70 (14%), p = 0.07)}. Follow up MACCE after 1 year reported in {6 subjects (5.6 %) vs 80 (16 %), p 0.= 4} in thrombectomy vs conventional group respectively.CONCLUSION:Thrombus aspiration before primary PCI (in a selected group with thrombus score ≥ 3) improves myocardial perfusion, suggested by better ST-segment resolution, TIMI flow, less peak CKMB and MBG, associated with a higher rate of direct stenting, shorter stent length, stented segments and less number of stents. Although thrombus aspiration was done in more risky patients (higher thrombus score) MACCE (in hospital and 1 year follow up) showed no statistical difference.

Assessment of Efficiency of Using Clinical Pulmonary Infection Score (CPIS) on Length of Stay (LOS) among Mechanically Ventilated Cases

AbstractBackground: VAP is pneumonia that develops in a me-chanically ventilated patient with a first positive bacterial culture beyond 48 hours after hospital admission or tracheal intubation, whichever occurred first. VAP burden relies on the increase of morbidity, cost, prolonged MV, ICU-Length of Stay (LOS) and hospital-length of stay.Aim of Study: Improve health outcome of patients on Mechanical Ventilation (MV) through early diagnosis of (VAP), early management with appropriate antibiotics pre-scription using Clinical Pulmonary Infection Score (CPIS) and to decrease MV days, ICU-Length of Stay (LOS) and hospital-length of stay.Methods: Operational research, quasi-experimental inter-ventional study design. The study was conducted in the in Critical Care Department in the Faculty of Medicine Cairo-University. The study has 2 phases Phase 1: Recruiting the Control group (40 cases) on MV not using CPIS. Phase 2: Recruiting the Interventional group (40 cases) on MV using CPIS.Results: The most common organism in control group was Klebsiella 25% and in intervention group was MRSA 17.5%. The ICU LOS was significantly lower in patients who were followed by CPIS in intervention group.Conclusion: CPIS considered tool to monitor patient's condition on MV for early modification which in turn reflected on ventilator days and ICU length of stay.

CLINICAL, LABORATORY CHARACTERISTICS AND TREATMENT RESULTS OF VENTILATOR-ASSOCIATED PNEUMONIA AT HUE UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Background: Ventilator-associated pneumonia (VAP) are frequently nosocomial infections at intensive care units (ICU). VAP result in increasing ICU stay, cost and mortality rate. Microorganisms which caused VAP were variety, change of state continously with high rate antibiotic-resistance. For the high quality of treatment therapy, physians must be care about etiology, clinical and laboratory characteristics of VAP for prevention and target treatment. Objectives: To describe the clinical and laboratory characteristics of VAP and comment the result of VAP treatment. Materials and method: Cross-section study of 30 patients who were diagnosed VAP from 04/01/2017 to 04/01/2018 at Anesthesia and Critical Care Department of Hue University of Medicine and Pharmacy Hospital. Results: Mean age of patients was 72.3 ± 14.3. Early VAP was 30%, lately VAP was 70%. Fever and increase mucus sputum were main clinical characteristics of VAP. Microorganisms which caused disease were A. baumannii, S. aureus, P. aeruginosa and Enterobacter spp with high rate antibiotic resistance. Mean mechanical ventilation was 16.8 ± 9.3 days. Mean ICU treatment was 23.7 ± 11.7 days. The mortality of VAP was 46.6%. Conclusion: VAP caused increase ICU stay and mortality rate of patients. It’s essential in a bundle care for VAP prevention and early treatment based on VAP etiology. Key words: Ventilator-associated pneumonia (VAP)

Not Just Hocus POCUS: Implementation of a Point of Care Ultrasound Curriculum for Internal Medicine Trainees at a Large Residency Program.

In 2018, the American College of Physicians formally acknowledged the importance of Point of Care Ultrasound (POCUS) to the practice of internal medicine (IM). For the military internist, POCUS training is critical for care of the trauma patient in austere environments, mass casualty events and natural disasters. While emergency medicine and critical care training programs have adopted POCUS education, few IM programs have integrated POCUS into their core curricula. We designed and implemented an iterative POCUS curriculum for trainees at a large military IM residency program over a two-year period. In collaboration with our critical care and simulation departments, we developed a pilot curriculum consisting of five, 60-minute courses offered on a voluntary basis at monthly intervals throughout 2017. Based on the pilot's success we incorporated a POCUS curriculum into the core academics received by all IM trainees during the 2017-2018 academic year. Trainees attended seven, 3-hour sessions during their scheduled academic time taught by subspecialists with POCUS expertise in an on-site simulation center. Baseline surveys and knowledge assessment examinations were administered during orientation and repeated at the end of the academic year. Comparison of results before and after the POCUS curriculum was the primary outcome evaluated. Intervention #1: Pilot, 2016-2017 Academic Year45 trainees attended at least one course with an average of 1.8 sessions per trainee. Baseline survey data showed 91% of trainees believe POCUS is quite or extremely beneficial for their patients, but 73% feel slightly or not at all confident in POCUS knowledge. The pre-test mean and median scores were 71% and 77% respectively, which both increased to a post-test mean and median of 81%. Post-test mean percentage correct for trainees attending 1, 2, or 3 courses was 74%, 82%, and 91% respectively. Intervention #2: Incorporation of POCUS into Core Academics, 2017-2018 Academic YearAll 75 trainees participated in training with an average of 3.77 sessions attended per trainee. Survey analysis revealed significant improvement in confidence of performing ultrasound-guided procedures (p = 0.0139), and a 37% absolute increase in respondents who anticipate using ultrasound in their clinical practice (p = 0.0003). The mean pre-test score was 67.8% with median of 63.6% while mean and median post-test scores were 82.1% and 81.8%, with an absolute improvement of 14.3% and 18.2% respectively (p = 0.0004). A structured POCUS curriculum was successfully incorporated at a large multiservice military IM residency program, with demonstrated retention of knowledge, improved confidence in performance of ultrasound guided invasive procedures, and increased interest in the use of POCUS in future clinical practice. Similar programs should be implemented across all IM programs in military graduate medical education to enhance operational readiness and battlefield care.

The Efficacy and Safety of using Nebulized Antibiotics in Treatment of Ventilator-Associated Pneumonia

Development of ventilator- associated pneumonia [VAP] is associated with high morbidity and mortality rates. VAP mortality ranges between 5.8% and 27% [1]. Routine administration of intravenous antibiotics does not reach a bactericidal concentration in lung tissues. intravenous antibiotics are mainly detected in respiratory segments of lungs, but not in sputum [2].This study was conducted on 60 patients who were admitted to critical care department at Benha University Hospital and diagnosed with Ventilator Associated Pneumonia [VAP]. patients were divided into two groups: Group A included 30 patients have received only systemic antibiotics and Group B included 30 patients have received systemic and nebulized antibiotics. In this study the clearance of organism, resistance, superinfection and combined [resistance and super infection] were significantly different in group A vs.B .There was significant decrease regarding creatinine level in group B vs. A .There were significant reduction in duration of MV and length of ICU stay in group B vs. A.Nebulized Amikacin plus ceftazidime are effective in the treatment of VAP.

Effect of Educational Program About Care of Patients Connected to Extracorporeal Membrane Oxygenation (ECMO) on Nurses Knowledge and Practices

AbstractBackground: Extracorporeal membrane oxygenation (EC-MO) or Extracorporeal life support (ECLS) is a technique of providing both cardiac and respiratory support for apatient whose heart and lung are unable to provide an adequate gas exchange to sustain life. Therefore, crtical care nurses should have specific knowledge and practice to provide safe, and efficient care for such group of patients.Aim of Study: This study was carried out to evaluate the effect of ECMO educational program on nurses' knowledge and practices.Subject and Methods: A quasi-experimental research design was utilized in the current study. Research hypotheses:(1)Critical care nurses who attend the educational program about care of patient connected to ECMO will have a higher post-test mean knowledge scores as compared to their pre-test mean knowledge scores all through the assessment times.(2)Critical care nurses who attend the educational program about care of patients connected to ECMO will have a higher post mean practice scores as compared to their pre-test mean practice scores all through the assessment times. A conven-ience sample of 34 nurses was included in the current study. The study was conducted in a selected Critical Care Depart-ment affiliated to Cairo University Hospitals. Three tools were utilized to collect data pertinent to the study: Critical care nurses personal Data sheet; Critical care Nurses' knowl-edge Questionnaire regarding care of patients connected to ECMO; and Critical Care Nurses' observational check list about care of patient connected to ECMO. The current study revealed that, the majority (94.1%) of nurses did not attend any training courses about care of patient connected to ECMO. The two stated research hypotheses were supported indicating significant improvement of critical care nurses knowledge and practices after implementation of ECMO educational program (F-ratio 494.8 at p£0.0001* & 242.204 at p£.0001 respectively).Conclusion: Impementation of a nursing educational program about care of patient connected to ECMO helped in assessment and enhancement of nursing knowledge and prac-tices. This will be reflected on critically ill patients' care.Recommendations: Carrying out in-service training, work-shops and continuing educational program a bout ECMO; provision of written guidelines about care of patients on ECMO; and strict observation of nurses practices.

Editorial introductions

Editorial introductions