Practices and Perspectives in Cardiopulmonary Resuscitation Attempts and the Use of Do Not Attempt Resuscitation Orders: A Cross-sectional Survey in Sri Lanka.

Objective: The objective of this study is to describe the characteristics of in-hospital cardiopulmonary resuscitation (CPR) attempts, the perspectives of junior doctors involved in those attempts and the use of do not attempt resuscitation (DNAR) orders. Methods: A cross-sectional telephone survey aimed at intern doctors working in all medical/surgical wards in government hospitals. Interns were interviewed based on the above objective. Results: A total of 42 CPR attempts from 82 hospitals (338 wards) were reported, 3 of which were excluded as the participating doctor was unavailable for interview. 16 (4.7%) wards had at least 1 patient with an informal DNAR order. 42 deaths were reported. 8 deaths occurred without a known resuscitation attempt, of which 6 occurred on wards with an informal DNAR order in place. 39 resuscitations were attempted. Survival at 24 h was 2 (5.1%). In 5 (13%) attempts, CPR was the only intervention reported. On 25 (64%) occasions, doctors were "not at all" or "only a little bit surprised" by the arrest. Conclusions: CPR attempts before death in hospitals across Sri Lanka is prevalent. DNAR use remains uncommon

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

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Rational use of ultrasonography with triaging of patients to detect dengue plasma leakage in resource limited settings: a prospective cohort study

Objectives: To compare the traditional haematocrit-based criteria (>20% rise above baseline) with ultrasonography for diagnosing plasma leakage in dengue fever and to identify clinical indicators for triaging patients in resource-limited settings when the demand for ultrasonography is high. Methods: The Colombo Dengue Study is a prospective observational cohort study recruiting dengue patients in the first three days of dengue fever, before plasma leakage. Serial haematocrit assessments and ultrasonography were performed in patients recruited from October 2017 to February 2020. Clinical signs/symptoms and laboratory investigation results independently associated with ultrasound detected plasma leakage were identified with a derivation cohort and confirmed in a validation cohort. Results: 129 of 426 patients had ultrasonography-confirmed plasma leakage while 146 had a haematocrit rise >20%. Those positive on ultrasonography were also likely to fulfil the haematocrit-based criteria (OR: 4.42, 95% CI: 2.85–6.86), but the two groups did not overlap fully. In the derivation cohort (n = 317), platelet count  51 IU/l and having abdominal pain in the first three days of fever were independent predictors of ultrasound-detected plasma leakage. In the validation cohort (n = 109), the combination of low platelet count and high aminotransferase level had better predictive capacity in terms of sensitivity and specificity. Conclusion: Dengue patients should be monitored with both serial haematocrit and ultrasonography whenever possible and plasma leakage should be diagnosed by either one of these criteria. If accessibility to scans is limited, platelet count, serum transaminase levels and presence of abdominal pain are useful to triage patients

Dengue and post-infection fatigue: Findings from a prospective cohort-the Colombo Dengue Study

Background: Previous studies on post-infection fatigue in dengue are few but suggest that up to 25% of dengue patients may suffer from fatigue. This study aimed to evaluate the prevalence and associations of post-infection fatigue in dengue patients compared with non-dengue fever patients. Methods: Post-infection fatigue and its demographic and clinical associations were assessed in adult dengue and non-dengue fever patients 2 months after the acute infection in a prospective cohort study in Sri Lanka. Fatigue at 2 months (primary endpoint) was assessed with the fatigue questionnaire as a dichotomous outcome based on a pre-recommended cut-off (score ≥4) and as the total score from the questionnaire (higher score indicates more fatigue). Results: Of 260 patients, 158 had dengue and, of these, 51 (32%) had fatigue at 2 months. Risk was higher in dengue patients (vs non-dengue; relative risk [RR] 4.93 [95% confidence interval {CI} 2.3 to 10.4]) and more so in female dengue patients (vs male dengue patients; RR 2.45 [95% CI 1.24 to 4.86]). Severe dengue patients had a higher mean fatigue score (p=0.024). Conclusions: Post-infection fatigue is an underappreciated burden of this widely prevalent infection. Our findings are useful to triage patients at risk of fatigue for follow-up

To: The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil

We congratulate the Epimed collaborators(1) on their impressive results from a privately owned registry in Brazil, an upper-middle income country. In addition to the examples from high income countries cited by the authors, Sri Lanka - a lower-middle-income country in South Asia - has implemented a national cloud-based intensive care unit (ICU) registry,(2) directly overseen by the Ministry of Health and Information and Communications Technology Agency (ICTA), in partnership with other national and overseas collaborators, including the Dutch National Intensive Care Evaluation (NICE) foundation. Founded in 2012, the cloud-based critical care unit registry, as part of a codesigned agile mobile data platform, the so called Network for Improving Critical Care Systems and Training (NICST; www.nicst.com), encompasses almost the entire network of state ICUs island-wide and includes pediatric, neonatal and specialized units

To: The Epimed Monitor ICU Database®: a cloud-based national registry for adult intensive care unit patients in Brazil

We congratulate the Epimed collaborators(1) on their impressive results from a privately owned registry in Brazil, an upper-middle income country. In addition to the examples from high income countries cited by the authors, Sri Lanka - a lower-middle-income country in South Asia - has implemented a national cloud-based intensive care unit (ICU) registry,(2) directly overseen by the Ministry of Health and Information and Communications Technology Agency (ICTA), in partnership with other national and overseas collaborators, including the Dutch National Intensive Care Evaluation (NICE) foundation. Founded in 2012, the cloud-based critical care unit registry, as part of a codesigned agile mobile data platform, the so called Network for Improving Critical Care Systems and Training (NICST; www.nicst.com), encompasses almost the entire network of state ICUs island-wide and includes pediatric, neonatal and specialized units

Critical care junior doctors' profile in a lower middle-income country: A national cross-sectional survey.

Background and Aims Retention of junior doctors in specialties such as critical care is difficult, especially in resource‑limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle‑income country. Materials and Methods This was a national cross‑sectional survey using an anonymous self‑administered electronic questionnaire. Results Five hundred and thirty‑nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P &lt; 0.05) between the self‑assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P &lt; 0.05). ICU postings were less happy and more stressful compared to the last non‑ICU posting (P &lt; 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10. Conclusion Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.</p

Experiences of ICU survivors in a low middle income country - A multicenter study

Background Stressful patient experiences during the intensive care unit (ICU) stay is associated with reduced satisfaction in High Income Countries (HICs) but has not been explored in Lower and Middle Income Countries (LMICs). This study describes the recalled experiences, stress and satisfaction as perceived by survivors of ICUs in a LMIC. Methods This follow-up study was carried out in 32 state ICUs in Sri Lanka between July and December 2015.ICU survivors’ experiences, stress factors encountered and level of satisfaction were collected 30 days after ICU discharge by a telephone questionnaire adapted from Granja and Wright Results Of 1665 eligible ICU survivors, 23.3% died after ICU discharge, 49.1% were uncontactable and 438 (26.3%) patients were included in the study. Whilst 78.1% (n = 349) of patients remembered their admission to the hospital, only 42.3% (n = 189) could recall their admission to the ICU. The most frequently reported stressful experiences were: being bedridden (34.2%), pain (34.0%), general discomfort (31.7%), daily needle punctures (32.9%), family worries (33.6%), fear of dying and uncertainty in the future (25.8%). The majority of patients (376, 84.12%) found the atmosphere of the ICU to be friendly and calm. Overall, the patients found the level of health care received in the ICU to be “very satisfactory” (93.8%, n = 411) with none of the survivors stating they were either “dissatisfied” or “very dissatisfied”. Conclusions In common with HIC, survivors were very satisfied with their ICU care. In contrast to HIC settings, specific ICU experiences were frequently not recalled, but those remembered were reported as relatively stress-free. Stressful experiences, in common with HIC, were most frequently related to uncertainty about the future, dependency, family, and economic concerns.</p

Evaluation of the feasibility and performance of early warning scores to identify patients at risk of adverse outcomes in a low-middle income country setting

Objective This study describes the availability of core parameters for Early Warning Scores (EWS), evaluates the ability of selected EWS to identify patients at risk of death or other adverse outcome and describes the burden of triggering that front-line staff would experience if implemented. Design Longitudinal observational cohort study. Setting District General Hospital Monaragala Participants All adult (age &gt;17 years) admitted patients. Main outcome measures Existing physiological parameters, adverse outcomes and survival status at hospital discharge were extracted daily from existing paper records for all patients over an 8-month period. Statistical Analysis Discrimination for selected aggregate weighted track and trigger systems (AWTTS) was assessed by the area under the receiver operating characteristic (AUROC) curve. Performance of EWS are further evaluated at time points during admission and across diagnostic groups. The burden of trigger to correctly identify patients who died was evaluated using positive predictive value (PPV). Results Of the 16 386 patients included, 502 (3.06%) had one or more adverse outcomes (cardiac arrests, unplanned intensive care unit admissions and transfers). Availability of physiological parameters on admission ranged from 90.97% (95% CI 90.52% to 91.40%) for heart rate to 23.94% (95% CI 23.29% to 24.60%) for oxygen saturation. Ability to discriminate death on admission was less than 0.81 (AUROC) for all selected EWS. Performance of the best performing of the EWS varied depending on admission diagnosis, and was diminished at 24 hours prior to event. PPV was low (10.44%). Conclusion There is limited observation reporting in this setting. Indiscriminate application of EWS to all patients admitted to wards in this setting may result in an unnecessary burden of monitoring and may detract from clinician care of sicker patients. Physiological parameters in combination with diagnosis may have a place when applied on admission to help identify patients for whom increased vital sign monitoring may not be beneficial. Further research is required to understand the priorities and cues that influence monitoring of ward patients.</p

Comparison of quick sequential organ failure assessment and modified systemic inflammatory response syndrome criteria in a lower middle income setting

Introduction: Quick Sequential Organ Failure Assessment (qSOFA) is potentially feasible tool to identify risk of deteriorating in the context of infection for to use in resource limited settings. Purpose: To compare the discriminative ability of qSOFA and a simplified systemic inflammatory response syndrome (SIRS) score to detect deterioration in patients admitted with infection. Methods: Observational study conducted at District General Hospital Monaragala, Sri Lanka, utilising bedside available observations extracted from healthcare records. Discrimination was evaluated using area under the receiver operating curve (AUROC). 15,577 consecutive adult ( ≥ 18 years) admissions were considered. Patients classified as having infection per ICD-10 diagnostic coding were included. Results: Both scores were evaluated for their ability to discriminate patients at risk of death or a composite adverse outcome (death, cardiac arrest, intensive care unit [ICU], admission or critical care transfer). 1844 admissions (11.8%) were due to infections with 20 deaths (1.1%), 29 ICU admissions (1.6%), 30 cardiac arrests and 9 clinical transfers to a tertiary hospital (0.5%). Sixty-seven (3.6%) patients experienced at least one event. Complete datasets were available for qSOFA in 1238 (67.14%) and for simplified SIRS (mSIRS) in 1628 (88.29%) admissions. Mean (SD) qSOFA score and mSIRS score at admission were 0.58 (0.69) and 0.66 (0.79) respectively. Both demonstrated poor discrimination for predicting adverse outcome AUROC = 0.625; 95% CI, 0.56-0.69 and AUROC = 0.615; 95% CI, 0.55- 0.69 respectively) with no significant difference (p value = 0.74). Similarly, both systems had poor discrimination for predicting deaths (AUROC = 0.685; 95% CI, 0.55-0.82 and AUROC = 0.629; 95% CI, 0.50-0.76 respectively) with no statistically significant difference (p value = 0.31). Conclusions: qSOFA at admission had poor discrimination and was not superior to the bedside observations featured in SIRS. Availability of observations, especially for mentation, is poor in these settings and requires strategies to improve reporting