Remifentanil apnea: Case report and review of the literature

Remifentanil is an opioid analgesic frequently used in intensive care patients because of its rapid onset of action, potency, and ultra-short duration. If an excessive dose is given, it leads to rapid, short lasting, potentially life-threatening side effects such as apnea, bradycadia, hypotension, and rigidity, following rapid peak serum levels. We report a 36-year-old woman developing apnea with bradycardia and hypotension, following an infusion in the central venous catheter lumen that had been used for remifentanil till tracheal extubation. The patient was immediately ventilated with bag-valve-mask and improved within 8 minutes. She became fully awake, heart rate and blood pressure returned to normal, and oxygen saturation improved to 100%. Acute care physicians, intensivists, anesthesiologists, and critical care nurses should be aware of this clinical problem in order prevent it as much as possible and to initiate immediate resuscitative measures

Fatal dialysis disequilibrium syndrome: A tale of two patients

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12. Conclusion: In patients with severe sepsis/septic shock, DDS may occur even after repeated sessions of HD. The acute care physicians, intensivists, and nephrologists should be aware of the risks of DDS

A theoretically informed, mixed-methods study of pharmacists’ aspirations and readiness to implement pharmacist prescribing

Background Studies have highlighted advancing clinical pharmacy practice in Qatar. Objective To explore pharmacists’ aspirations and readiness to implement pharmacist prescribing. Setting Hamad Medical Corporation (HMC), the main provider of secondary and tertiary care. Method A sequential explanatory mixed-methods design. Questionnaire items were derived from the Consolidated Framework of Implementation Research (CFIR), in domains of: awareness/support; readiness; implementation; and facilitators and barriers. Following piloting, all pharmacists (n = 554) were invited to participate. Questionnaire data were analysed using descriptive and inferential statistics with principal component analysis of attitudinal items. Focus groups were recorded, transcribed and analysed using the Framework Approach. Main outcome measure Aspirations and readiness to implement pharmacist prescribing. Results The response rate was 62.8% (n = 348), with respondents highly supportive of implementation in Qatar (median 4, scale 0–5, extremely supportive). The majority (64.9%, n = 226) considered themselves ready, particularly those more senior (p < 0.05) and classifying themselves innovative (p < 0.01). Outpatient (72.9%, n = 221 agreeing) and inpatient (71.1%, n = 218 agreeing) HMC settings were those perceived as being most ready. PCA identified 2 components, with ‘personal attributes’ being more positive than ‘prescribing support’. Facilitators were access to records, organizational/management support and the practice environment, with physician resistance and scope of practice as barriers. Focus groups provided explanation, with themes in CFIR domains of innovation characteristics, characteristics of individuals and the inner setting. Conclusion HMC pharmacists largely aspire, and consider themselves ready, to be prescribers with inpatient and outpatient settings most ready. CFIR domains and constructs identified as facilitators and barriers should be focus for implementation.Open access funding provided by the Qatar National Library. Funding was received from the Medical Research Center, Hamad Medical Corporation, Qatar

Fatal dialysis disequilibrium syndrome: A tale of two patients

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12

Metered-dose inhaler technique among healthcare providers practising in Oman

Objective: To evaluate the correctness of metered-dose inhaler (MDI) technique in a sample of healthcare providers practicing in Oman, considering that poor inhaler technique is a common problem both in asthma patients and healthcare providers, which contributes to poor asthma control. Method: A total of 150 healthcare providers (107 physicians, 33 nurses and 10 pharmacists) who were participants in symposia on asthma management conducted in five regions of Oman, volunteered for the study. After the participants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counseling, a trained observer assessed their MDI technique using a checklist of nine steps. Results: Of the 150 participants, 148 (99%) were involved in teaching inhaler techniques to patients, and 103 of 107 physicians (96%) had prescribed inhaled medications. However only 22 participants (15%) performed all steps correctly. Physicians performed significantly better than non-physicians (20% vs. 2%, p &lt;0.05) among the physicians, internists performed better (26%) than general practitioners (5%) and accident and emergency doctors (9%). Conclusion: The majority of healthcare providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly indicating the need for regular formal training programmes on inhaler techniques.

A scoping review of theories used to investigate clinician adherence to clinical practice guidelines

Background: Routine utilization of evidence-based clinical practice guidelines (CPGs) is an effective strategy to optimize patient care and reduce practice variation. Healthcare professionals’ failure to adhere to CPGs introduces risks to both patients and the sustainability of healthcare systems. The integration of theory to investigate adherence provides greater insight into the often complex reasons for suboptimal behaviors. Aim: To determine the coverage of literature surrounding the use of theory in studies of CPG adherence, report the key findings and identify the knowledge gaps. Method: In April 2021, three bibliographic databases were searched for studies published since January 2010, adopting theory to investigate health professionals’ adherence to CPGs. Two reviewers independently screened the articles for eligibility and charted the data. A narrative approach to synthesis was employed. Results: The review includes 12 articles. Studies were limited to primarily investigations of physicians, quantitative designs, single disease states and few countries. The use of behavioral theories facilitated pooling of data of barriers and facilitators of adherence. The domains and constructs of a number of the reported theories are captured within the Theoretical Domains Framework (TDF); the most common barriers aligned with the TDF domain of environmental context and resources, fewer studies reported facilitators. Conclusion: There is emerging use of behavioral theories investigating physicians’ adherence to CPGs. Although limited in number, these studies present specific insight into common barriers and facilitators, thus providing valuable evidence for refining existing and future implementation strategies. Similar investigations of other health professionals are warranted.Open Access funding provided by the Qatar National Library. No funds were sourced to conduct this study

The cost associated with the development of the antimicrobial stewardship program in the adult general medicine setting in Qatar

Objective: To estimate the economic impact of the developed antimicrobial stewardship program (ASP) versus the preliminary ASP use, in the adults' general medicine settings in Qatar. Methods: Patient records were retrospectively reviewed during two periods: preliminary ASP was defined as the 12 months following ASP implementation (i.e. May 2015-April 2016), and developed ASP was defined as the last 12 months of a 5-year ASP implementation in Hamad Medical Corporation (HMC) (i.e. February 2019-January 2020). The economic impact was the overall cost savings in resource use, including operational costs, plus the cost avoidance associated with ASP. Results: A total of 500 patients were included in the study. The operational costs decreased with the developed ASP. Whereas antimicrobial consumption and resource utilisation, and their associated costs, appear to have declined with the developed ASP, with a cost saving of QAR458 (US$125) per 100-patient beds, the avoided cost was negative, by QAR4,807 (US$1,317) per 100-patient beds, adding to a total QAR4,224 (US$1,160) increase in the 100-patient beds cost after ASP development. Conclusions: Despite that the developed ASP attained a total cost saving QAR458 (US$125) per 100-patient beds, the avoided cost was QAR-4,807 (US$-1,317) per 100-patient beds, which exceeded the cost savings achieved.Medical Research Center, Hamad Medical Corporation, Doha, Qatar supported this work; Grant number: MRC-01-20-213. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript. Open Access funding provided by the Qatar National Library, Qatar.Scopu