Retrospective review of the use of Swan Ganz catheters in our intensive care unit (ICU): a short report

The widespread and often \u27misuse\u27 of the Swan Ganz (SG) or Pulmonary artery catheter has often been seen in intensive care patients. The objective of this preliminary review was to observe the trends and possibly formulate an association with outcome of the use of SG catheters as well as to determine the frequency of use and possible complications. The chart review of ten patients was carried out for the months of January and February 2004 in a retrospective manner. The incidence of SG catheter insertion was 12% per month on average. Nine out of 10 patients received the SG catheters for \u27fluid management\u27; and 1 for \u27haemodynamic instability\u27. Eight out of 10 patients expired and average length of stay was 9 days. There were no complications recorded. The cause of death in all patients was \u27severe sepsis\u27. The overwhelming majority of patients who received these catheters expired at the end of their stay

One year experience of MRI under general anaesthesia

A case series over one year of our experience of using Propofol and Laryngeal mask airway (LMA) in children under 10 years of age undergoing MRI under general anaesthesia is presented. All paediatric patients under the age of ten attending out-patient department were included in the case series starting from January 1st, 2004 till December 31st, 2004. All patients underwent general anaesthesia using Propofol / LMA technique as described in detail in communication below. A total of 78 children were included; the only patient requiring intubation was the youngest: a neonate of 1 day who had a large orbital mass. Propofol in the dose of 2 mg/kg and an appropriate size LMA according to weight of the patient was used. Majority of the patients (67) had a brain or head MRI for \u27developmental delay\u27, 5 patients had a brain MRI for a \u27mass lesion\u27 and 5 patients had a lumbo-sacral MRI for \u27abnormal growth\u27. There was only one complication when a child with history of seizures, seized on recovery and had to be subsequently admitted to the Emergency Room for observation. No other morbidity or mortality was noted. All patients were outpatients. We can conclude based on our results that providing GA for paediatric patients undergoing MRI with Propofol and LMA can be safe and effective in outpatient radiology

Audit on preoperative midazolam and level of sedation

We wished to observe by carrying out a prospective clinical audit, the level of sedation and time interval of all adult elective surgery patients. We enrolled adult ASA I-III patients who came for elective surgery to the Aga Khan University Hospital preoperative surgery suite for 3 months. Hundred patients were enrolled. The majority of patients got 7.5 mg of PO Midazolam. Our median Ramsay sedation score was 2 and the Median drug to door time was 52.35 minutes. 11 patients were reportedly \u27drowsy\u27 in the recovery room one hour after surgery was completed. These were mostly the same patients who had a higher (Ramsay V) sedation score in the preoperative period (p = 0.36). There was no significant difference in the 2 midazolam dosages and the Ramsay sedation score (p = 0.12). We concluded that our sedation score is too low and our median time interval is too long making most patients coming for surgery under sedated. We recommend calling the patients in the OR suite one hour prior and the dosage being prescribed by the primary anaesthetist in order to keep this standardized

PGE1 nebulisation during caesarean section for Eisenmenger\u27s syndrome: a case report.

Introduction: Eisenmenger\u27s syndrome in pregnancy can lead to death in 50% to 65% of parturients. Expensive invasive monitoring and medication have improved management and outcomes. Cheaper alternatives for the management of high-risk Patients who present with no prenatal care are still not available. Case Presentation: We describe the obstetric anaesthesia management of a 34-year-old, 34-weeks pregnant woman who presented with a recent diagnosis of severe Eisenmenger\u27s syndrome. A combined spinal epidural anaesthesia was used together with invasive cardiac monitoring as well as PGE1 nebulisation after delivery of the baby. This helped achieve a reduction of shunt, improvement of hypoxia and reduction of pulmonary pressures. Conclusion: We found this to be a cheaper and safe alternative in the management of such Patients who present with no adequate prior management

Administración inmediata versus tardía de antibióticos de amplio espectro antes del ingreso a la unidad de cuidados intensivos para la sepsis severa en adultos

ResumenAntecedentesLa sepsis grave y el shock séptico han surgido recientemente como retos particularmente agudos y letales en los pacientes en estado crítico que se presentan al servicio de urgencias (SU). No hay datos sobre las prácticas actuales para el tratamiento de los pacientes con sepsis grave que comparen la administración inmediata versus tardía de los antibióticos de amplio espectro apropiados como parte del tratamiento precoz dirigido al objetivo, que comienza en las primeras horas de presentación.ObjetivosEvaluar la diferencia de los resultados de la administración inmediata versus tardía de antibióticos en los pacientes con sepsis grave antes del ingreso en la unidad de cuidados intensivos (UCI). Se definió inmediata como la primera hora después de la presentación en el SU.Estrategia de búsquedaSe realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library número 1, 2009); MEDLINE (1990 hasta febrero 2010); EMBASE (1990 hasta febrero 2010); e ISI web of Science (febrero 2010). También se hicieron búsquedas de ensayos relevantes en curso en sitios web específicos como www.controlled-trials.com; www.clinicalstudyresults.org; y www.update-software.com. Se hicieron búsquedas en las listas de referencias de artículos. No hubo restricciones basadas en el idioma o en el estado de la publicaciónCriterios de selecciónSe planeó incluir ensayos controlados aleatorios de la administración inmediata versus tardía de antibióticos de amplio espectro en pacientes adultos con sepsis grave en el SU, antes del ingreso a la unidad de cuidados intensivos.Obtención y análisis de los datosDos autores, de forma independiente, evaluaron los artículos para la inclusiónResultados principalesNo se encontraron estudios que cumplieran los criterios de inclusión.Conclusiones de los autoresBasado en esta revisión no se pueden hacer recomendaciones sobre el uso inmediato o tardío de los antibióticos de amplio espectro en los pacientes adultos con sepsis grave en el SU antes del ingreso en la UCI. Es necesario realizar ensayos controlados aleatorios doble ciegos prospectivos amplios sobre la eficacia de la administración inmediata (en una hora) versus tardía de antibióticos de amplio espectro en los pacientes adultos con sepsis grave. Como tiene sentido comenzar los antibióticos tan pronto como sea posible en este grupo de pacientes gravemente enfermos, la administración inmediata de tales antibióticos en contraposición a la administración tardía se basa en pruebas anecdóticas subóptimas.Resumen en términos sencillosEvaluar el momento óptimo de administrar los antibióticos a los pacientes con sepsis en el servicio de urgenciasLa sepsis es un trastorno médico grave caracterizado por una respuesta inflamatoria a una infección que puede afectar todo el cuerpo. El paciente puede desarrollar una respuesta infamatoria a los microbios en su sangre, orina, pulmones, piel u otros tejidos. La sepsis es una enfermedad grave con una tasa de mortalidad muy alta si no se trata. La mayoría de los pacientes con sepsis requieren antibióticos y el ingreso en una unidad de cuidados intensivos (UCI). No puede aún precisarse la rapidez con que los antibióticos de amplio espectro deben ser administrados. El tratamiento con antimicrobianos de amplio espectro se define como una combinación de antibióticos que actúan contra una amplia gama de bacterias que causan la enfermedad, suele reducir las tasas de mortalidad en los pacientes con sepsis, sepsis grave o shock séptico. Se realizó una revisión sistemática de la literatura mediante búsquedas en bases de datos fundamentales de materiales de alta calidad, publicados y no publicados, sobre el momento de administrar los antibióticos en el servicio de urgencias antes del ingreso en la UCI. Estas búsquedas no mostraron ensayos controlados aleatorios (ECA) sobre el momento de administrar tratamiento con antibióticos de amplio espectro en esta población. Se llegó a la conclusión de que es necesario realizar estudios observacionales de cohortes, a falta de ECA, aunque carezcan de la precisión de los ECA. También se concluyó que lo mejor es administrar los antibióticos inmediatamente. Es importante comprender que el reloj comienza a andar cuando el paciente llega al SU y se detiene cuando comienza a administrarse el antibiótico. El período antes de ingresar a la unidad de cuidados intensivos es el tiempo que se pasa en la sala o en el SU antes de ingresar a la UCI, donde se ingresa la mayoría de los pacientes con sepsis grave. La revisión tuvo un propósito definido muy específico, porque se centró sólo en los pacientes con sepsis grave y en encontrar sólo ECA. La ausencia de ECA puede implicar, en sí, la naturaleza complicada de la pregunta de estudio, ya que puede ser éticamente equivocado asignar al azar a tales pacientes a un brazo de tratamiento aparentemente inferior

Apache II score as a predictor of length of stay and outcome in our ICUs

The APACHE II (acute physiology and chronic health evaluation) is used widely for predicting probability of hospital mortality and length of stay in the ICU. APACHE II forms were available to all ICU residents within 24 hours of admission, and a score was assigned to them. Based on our results the APACHE II score has reliably predicted an outcome of the least amount of length of stay (LOS) in the ICU as well as a 100% probability of being shifted out of the ICU for a score of \u3c 10 (according to international benchmarks). This reliable scoring system can be used for predicting mortality and length of stay and therefore, resource allocation, antibiotic use and ethical decisions regarding counseling families about end of life decisions--all within 24 hours of admissions

Anaesthesia as a career choice in a developing country; effect of clinical clerkship

OBJECTIVE: To explore the fourth year medical student\u27s knowledge regarding anaesthesia as a specialty, their attitude towards anaesthesia as a career choice and the effect of clinical clerkship on these. METHODS: This survey was conducted in the Department of Anaesthesia of a university medical centre in a developing country. One hundred and fifty year four medical students rotating in anaesthesia were enrolled. They were asked to fill a structured questionnaire before (pre) and after (post) their anaesthesia rotation. The questionnaire sought information on their perception of anaesthesia as a specialty, role of anaesthetists clerkship duration, and reasons for considering or not considering anaesthesia. RESULTS: Prior to anaesthesia clerkship 12 students (8%) included anaesthesia in their first three career choices (2 as first preference). Post clerkship 36 (24%) included it in their first 3 career choices (3 as first preference). There was a change in perception of specialty for 57 participants. CONCLUSION: The findings support the positive influence of anaesthesia clerkship on changing the attitude of medical students towards anaesthesia specialty in a developing country with shortage of anaesthesia personnel

How early do antibiotics have to be to impact mortality in severe sepsis? A prospective, observational study from an emergency department

BACKGROUND: The objective of this study was to assess the promptness of antibiotic administration to patients presenting with sepsis and the effects on survival and length of hospitalization. METHODS: Consecutive, adult patients presenting with Systemic Inflammatory Response Syndrome (SIRS) to the emergency department of the Aga Khan University hospital were enrolled in a prospective, observational study over a period of 4 months. Univariate, multivariate regression modeling and one-way ANOVA were used to examine the effects of various variables on survival and for significant differences between timing of antibiotic administration and survival, two-sided p values \u3c 0.05 were considered significant. RESULTS: One hundred and eleven patients were enrolled. Severe sepsis was present in 52% patients; the most frequent organism isolated was Salmonella typhi (18%). Overall mortality was 35.1%. One hundred (90.1%) patients received intravenous antibiotics in the Emergency room; average time from triage to actual administration was 2.48 +/- 1.86 hours. The timing of antibiotic administration was significantly associated with survival (F statistic 2.17, p = 0.003). Using a Cox Regression model, we were able to demonstrate that survival dropped acutely with every hourly delay in antibiotic administration. On multivariate analysis, use of vasopressors (adjusted OR 23.89, 95% CI 2.16,263, p = 0.01) and Escherichia coli sepsis (adjusted OR 6.22, 95% CI 1.21,32, p = 0.03) were adversely related with mortality. CONCLUSIONS: We demonstrated that in the population presenting to our emergency room, each hourly delay in antibiotic administration was associated with an increase in mortality