ResearchPad - Critical Care Default RSS Feed en-us © 2020 Newgen KnowledgeWorks <![CDATA[Development and validation of a questionnaire to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy]]> Cardiac arrest is rare in pregnancy, and up-to date competence can be difficult to assess and maintain. The objective of this study was to develop and validate a questionnaire to assess healthcare personnel experiences, self-assessed competence and perception of role and resposibility related to cardiac arrest and cardio-pulmonary resuscitation (CPR) in pregnancyMethodsThe study had a cross-sectional design, developing and validating a questionnaire: the Competence in cardiac arrest and CPR in pregnancy (ComCA-P). Development and validation of the ComCA-P was conducted in three stages: 1) Literature review and expert group panel inputs, 2) a pilot study and 3) a cross-sectional questionnaire study. In stage one, the ComCA-P was developed over several iterations between the researchers, including inputs from an expert group panel consisting of highly competent professionals (n = 11). In stage two, the questionnaire was piloted in a group of healthcare personnel with relevant competence (n = 16). The ComCA-P was then used in a baseline study including healthcare personnel potentially involved in CPR in pregnancy (n = 527) in six hospital wards. Based on these data, internal consistency, intra-class correlations, and confirmatory factor analysis were utilized to validate the questionnaire.ResultsThe expert group and pilot study participants evaluated the appropriateness, relevance and accuracy to be high. Formulation of the items was considered appropriate, with no difficulties identified related to content- or face validity. Cronbach’s alpha was 0.8 on the thematic area self-assessment, and 0.73 on the theoretical knowledge area of the ComCA-P. On both the self-assessed competence items and the teoretical knowledge items, Kaiser-Meyer-Olkin was 0.8. Moreover, the Bertletts’ test of sphericity was greater than the critical value for chi-square, and significant (p < .0001).ConclusionsFindings indicate that the ComCA-P is a valid questionnaire that can be used to assess healthcare personnel competence in cardiac arrest and resuscitation in pregnancy. ]]> <![CDATA[Effect of experimental, morphological and mechanical factors on the murine spinal cord subjected to transverse contusion: A finite element study]]> Finite element models combined with animal experimental models of spinal cord injury provides the opportunity for investigating the effects of the injury mechanism on the neural tissue deformation and the resulting tissue damage. Thus, we developed a finite element model of the mouse cervical spinal cord in order to investigate the effect of morphological, experimental and mechanical factors on the spinal cord mechanical behavior subjected to transverse contusion. The overall mechanical behavior of the model was validated with experimental data of unilateral cervical contusion in mice. The effects of the spinal cord material properties, diameter and curvature, and of the impactor position and inclination on the strain distribution were investigated in 8 spinal cord anatomical regions of interest for 98 configurations of the model. Pareto analysis revealed that the material properties had a significant effect (p<0.01) for all regions of interest of the spinal cord and was the most influential factor for 7 out of 8 regions. This highlighted the need for comprehensive mechanical characterization of the gray and white matter in order to develop effective models capable of predicting tissue deformation during spinal cord injuries.

<![CDATA[Revised Triage and Surveillance Protocols for Temporary Emergency Department Closures in Tertiary Hospitals as a Response to COVID-19 Crisis in Daegu Metropolitan City]]>

<![CDATA[Vasospasm-related Sudden Cardiac Death Has Outcomes Comparable with Coronary Stenosis in Out-of-Hospital Cardiac Arrest]]>

<![CDATA[Advanced Pulmonary and Cardiac Support of COVID-19 Patients: Emerging Recommendations From ASAIO—A “Living Working Document”]]> The severe acute respiratory syndrome (SARS)-CoV-2 is an emerging viral pathogen responsible for the global coronavirus disease 2019 (COVID)-19 pandemic resulting in significant human morbidity and mortality. Based on preliminary clinical reports, hypoxic respiratory failure complicated by acute respiratory distress syndrome is the leading cause of death. Further, septic shock, late-onset cardiac dysfunction, and multiorgan system failure are also described as contributors to overall mortality. Although extracorporeal membrane oxygenation and other modalities of mechanical cardiopulmonary support are increasingly being utilized in the treatment of respiratory and circulatory failure refractory to conventional management, their role and efficacy as support modalities in the present pandemic are unclear. We review the rapidly changing epidemiology, pathophysiology, emerging therapy, and clinical outcomes of COVID-19; and based on these data and previous experience with artificial cardiopulmonary support strategies, particularly in the setting of infectious diseases, provide consensus recommendations from ASAIO. Of note, this is a “living document,” which will be updated periodically, as additional information and understanding emerges.

<![CDATA[The inaugural Qatar Critical Care Conference with its Qatar Medical Journal Special Issue – An important milestone]]>


Dr. Ibrahim Fawzy Hassan

Local Host and QCCC 2019 Conference Chair

Dear Friends and Colleagues,

It is an honour to welcome everyone to the first Qatar Critical Care Conference (QCCC). It has been a long journey to make it happen, but this event has been much awaited by the local critical care community. Over the last few years, we have hosted a number of related events of various scales, ranging from Critical Care Grand Rounds targeting Hamad Medical Corporation (HMC) critical care clinicians, ran specialised courses, through to organising an international medical conference on extracorporeal life support in 2017.1 This inaugural QCCC event is the fruit of much planning and collaboration. The programme spans from 28th to 31st October 2019 and consists of two days of pre-conference workshops and two days for the main conference.

The vast majority of the pre-conference workshops will be held in the state-of-the-art ITQAN Clinical Simulation and Innovation Centre located within Hamad bin Khalifa Medical City. Although the facility is yet to be offically inaugurated and opened, we have the privilege to have been granted access to it as a way of showcasing our forthcoming continuing professional development capability. “Itqan” in Arabic means quality and striving for perfection, which is very much in line with the mission of our established Critical Care Network (CCNW).2 Simulation-based education is an area in which we have started to be very active through various immersive courses as well as innovative technological developments to train our extracorporeal membrane oxygenation (ECMO) specialists.3,4

The scientific part of the conference will be hosted in the iconic Sheraton Grand Doha Resort & Convention Hotel in the West Bay area. It includes a varied selection of topics presented by many renowned experts in their respective domain. This comprehensive programme with a line-up of lectures and workshops addressing e-CPR, ECMO simulation, ECMO cannulation, hemodynamics and so much more will facilitate the exchange of knowledge and experiences to improve patient care in Qatar and beyond. We anticipate that the programme will appeal to a broad audience and hence will bring together clinicians from all professions involved with caring for acutely ill patients. It is QCCC's aim to connect and explore new insights and expertise at a national and international level through networking with other professionals in a multidisciplinary setting. We hope that during this event many fruitful discussions will take place and that it will enhance opportunities for collaboration to develop everyone's practice in critical care.

The HMC Critical Care family has a capacity of 163 and 109 intensive care unit (UCI) beds, respectively for adult and paediatric patients, across 7 hospitals spread throughout Qatar. These numbers are complemented by another 52 adult and paediatric beds from non-HMC hospitals. This gives us a national ICU bed capacity of 11.8 per 100,000 inhabitants considering a current population of nearly 2,750,000 inhabitants.5 Although this number remains below the international benchmark which can be considered to be around 15/100,000 population,6 this quota in Qatar has more than quadrupled over the last ten years, which represents a very significant improvement in the care that can be provided to acutely ill patients. Within HMC only, it is supported by a workforce of 159 intensive care physicians, 1122 intensive care nurses, and many other clinical staff, all of whom undergo a well regulated programme of continuing professional development and are licensed to practise by the Qatar Council for Healthcare Practitioners (QCHP).7 The work they do across the various sites is coordinated and monitored by the CCNW2 who ensures the best level of care, up-to-date technology, and evidence-based practices are consistently adopted for the wellbeing of our patients.

Once again, on behalf of the Scientific and Organizing Committees, it is my pleasure to welcome you all to Doha and we hope that you enjoy and gain meaningful insights during the conference regarding our local critical care setting and practices, but also learn from the experiences and best practices shared by our international guest speakers.

Prof. Guillaume Alinier

Guest Managing Editor, Qatar Medical Journal QCCC Special Issue and Abstracts Chair of the QCCC Scientific Committee.

Dear Contributors and Conferences Delegates,

Welcome to this special issue of the Qatar Medical Journal (QMJ) which has been dedicated to the inaugural conference of the Hamad Medical Corporation (HMC) Qatar Critical Care Network (QCCN) which celebrates its fifth anniversary in 2019. I would like to start by thanking everyone who has supported this arduous publication endeavour through their extended abstract submission(s) and the reviewers for the valuable feedback they have provided to the authors to ensure this publication is a representative legacy of the calibre of this conference which includes many local and international experts in their respective field of practice or interest. All the accepted abstracts are being published Open Access thanks to the support of the conference sponsors and this contributes greatly to the sharing of experiences and best practices worldwide, but also showcases the good work that is being done in Qatar in the domain of critical care thanks to the work of dedicated clinicians and the leadership of the CCNW.2

Being the Guest Managing Editor of the special issue of a journal is an honour but also an arduous task, especially when a large number of submissions from international authors needs to be handled. It is the second time that I have accepted to take on that role for Qatar Medical Journal as the previous time was in 2017 on the occasion of hosting the South West Asia and African Chapter (SWAAC) of the Extracorporeal Life Support Organisation (ELSO) in Doha.1 This was only a couple of years after HMC had established its Extracorporeal Membrane Oxygenation (ECMO) programme, and it was a very successful event with many of its associated open access publications having been downloaded hundreds of times from the publishing platform.

Working on this new Special Issue really made me reflect on how the domain of critical care is vast and encompasses so many aspects of patient care and so many professions and specialties. The topics of the abstracts published in this special issue of QMJ cover dietetics,8 sepsis,9 delirium,10,11 physical therapy,12 end of life care and organ donation,13,14 dealing with families,15 as well as education and training of clinicians,16,17 to only highlight a few. Critical care is fast moving as new clinical practices and technological innovations are adopted and contribute to continuously improving patient care. This is especially true in Qatar where significant investments are constantly made to develop and support healthcare in a strategic way.18 At HMC, the critical care phase that some patients have to go through so their medical needs can be met is well integrated across all stakeholder departments that can possibly be involved.2 The patient's journey through the healthcare system can be seen as a continuum of care facilitated by the fact that all parties involved belong to the same overarching organisation, HMC, which is the government funded main provider of secondary and tertiary healthcare in Qatar. This means that from initial contact with the Ambulance Service bringing a patient to the Emergency Department for example, right through to rehabilitation and even possible access upon discharge to a mobile healthcare service supported by family physicians, nurses, and paramedics, patients can expect the same high standards of care.19 Critical care provision relies on multidisciplinary communication during transition of care as well as during any acute episode. This needs to be underpinned by medical knowledge and understanding of the potential contributions of other professions as nothing can be left to chance when a patient's life is hanging by a thread. The present collection of editorials and abstracts brings different perspectives on a broad range of topics which should be highly relevant to all clinicians involved with critical care and contribute to improving patient outcome and satisfaction, and hence that of the multidisciplinary team members also involved in caring for them.

We hope that the Qatar Medical Journal Special Issue publications on critical care meets your needs and expectations. The complete record of QCCC publications including additional open access abstracts and editorials relating to this conference will be made available in Qatar Medical Journal at the following link: Thanks again to everyone for your contributions, and beyond our email communications, I now hope to meet you in person during the conference!

<![CDATA[A rare case of propofol related infusion syndrome in a neurosurgical patient]]>

Background: For the last three decades propofol has been used in anaesthesia and as a sedation technique. Several reports have warned about its use in higher doses for prolonged durations as it can have severe side effects such as propofol related infusion syndrome (PRIS), which can be fatal.1,2,3 PRIS is a rare and complex clinical condition characterized by severe metabolic acidosis, rhabdomyolysis, cardiac, liver and kidney dysfunction, and lipidemia. In its advanced stage PRIS can lead to severe refractory bradycardia and asystole.4,5

Propofol and remifentanil total intravenous anaesthesia (TIVA) is a popular anaesthesia technique. The target controlled infusion (TCI) gives predicted and controlled drug concentration and has added to the increased use of TIVA. Not much literature is available about the use of propofol and remifentanil TIVA and occurrence of PRIS. We report a case of PRIS in a neurosurgical patient with history of dyslipidemia. Case presentation: A 46-year old man weighing 68 kg, with a known case of hyperlipidemia, presented with decreased hearing on the left side, headache, and perioral numbness. Computerized tomography (CT) of the head showed left cerebropontine angle cystic lesion. His home medications were oral sodium chloride 1200 mg three times daily and pravastatin 20 mg once daily. He was electively scheduled for surgery under general anaesthesia, which lasted for seven hours. He received a TCI with propofol and remifentanil. He remained hemodynamically stable throughout the procedure.

Over 7 hours the patient received a total of 3332 mg of 1% propofol, remifentanil TCI 3–4 mcg/ml, ephedrine 18 mg, mannitol 20%–250 ml, pancuronium 16 mg, vecuronium 25 mg, cefazoline 2 g, dexamethasone 16 mg, neostigmine 5 mg, glycopyrolate 1 mg, and labetalol 25 mg. He received 2 liters of crystalloid and one liter of colloid during the surgery. Intra-operative blood sugar remained around 6–7 mmol/L and his central venous pressure was maintained between 8–11 mmHg.

His first arterial blood gas showed increasing lactate and metabolic acidosis after two hours of anaesthesia and it continued to rise till the end of surgery. He was extubated and shifted to the surgical intensive care unit (SICU) with a Glasgow Coma Score of 15, spontaneously breathing and with stable hemodynamics. The serum lactate continued to rise in SICU for the first 12 hours and then slowly started to decline (Figure 1). A graph of the trends of carbon dioxide and serum bicarbonate levels is shown in Figure 2. The triglycerides level reached 11.46 (Figure 3), creatine kinase 1852 U/L and myoglobin 474 ng/ml which showed decline within the next 24 hours.

He remained hemodynamically stable with adequate urine output. On day one we resumed atorvastatin 20 mg, labetalol prn, bicarbonate infusion. After 24 hours, his lactate levels were normalized and acidosis resolved. The patient was discharged without any complications.

Conclusion: Propofol TIVA with TCI is a common anesthesia practice. In a known dyslipidemic patient it will increase the risk for PRIS. In our patient, other risk factors for development of PRIS were higher dose, neurosurgical procedure, and extended duration of propofol infusion. The authors believe it is the first case of PRIS in a dyslipidemic patient undergoing neurosurgery with TIVA.

<![CDATA[Approach to circulation after cardiac surgery in children]]>

Pediatric intensivists are called to patient bedsides in the pediatric cardiac intensive care unit (CICU) after congenital cardiac surgery for low blood pressure (BP) and/or poor perfusion, acute change in heart rate (HR) or rhythm, surgical site bleeding or increased chest tube output, anuria or oliguria, oxygen desaturation less than expected or metabolic acidosis with rising lactic acid and base deficit. Causes of acute circulatory failure after cardiac surgery are divided into four categories which must be considered when approaching the patient in CICU (Table 1).

Assessing cardiac output in CICU remains challenging, hemodynamic parameters are usually monitored, along with physical examination, i.e. HR, BP, right and left atrial pressures. There are surrogate markers i.e., mixed venous saturation, brain and renal NIRS, toe temperature, urine output, and then laboratory workup to determine acidosis due to end-organ dysfunction. Echocardiography can confirm low cardiac output syndrome (LCOS) occurs after cardiac surgery with the following major indicators; abnormal ventricular-vascular interaction after bypass, the functionally univentricular circulation, abnormal diastolic function after surgery to the right heart and residual anatomic lesions.1

The limited support tools that are available to manage circulatory failure post cardiac surgery in the CICU are the following: Medications: High labile pulmonary vascular tone (PVR) occurs in patients with pulmonary over-circulation i.e., ASD (atrial septal defect), VSD (ventricular septal defect), PDA (patent ductus arteriosus) and AV canal (atrioventricular canal). Pulmonary venous hypertension, i.e. TAPVR with obstruction, HLHS with restrictive atrial communication and in the univentricular heart after Norwood, shunt or PA band has unstable PVR. Functionally univentricular hearts don't tolerate increased SVR and at the same time, decreased SVR may not be desirable for patients who have fixed systemic or pulmonary obstruction. There are a wide variety of medications to use, but essentially two, milrinone2,3 and epinephrine are very important and widely used. Milrinone is routinely used after cardiac surgery to minimize the LCOS, which works in a receptor independent manner and is synergistic to beta-adrenergic ionotropic effect. Most patients benefit from low dose epinephrine for decreased cardiac function. Nitroprusside is effective where after-load is high, a low dose should always be started titrating to the optimal BP. Generally, there is no role of dopamine in these patients.4 Ventilation-cardiopulmonary interaction: Ventilation at functional residual capacity needs to be targeted. Managing rhythm: Recognition of rhythm is a crucial aspect of care. It is equally important to pay attention to the appropriate heart rate. Extracorporeal mechanical support: The last resort is to put the patient on extracorporeal membrane oxygenation.

In summary, the past two decades have seen important advances in our understanding of the circulatory physiology of infants and children post cardiac surgery. When approaching the patients with cardiovascular dysfunction, it is essential to approach the cardiopulmonary system in its entirety, rather than consider the heart, lungs, or peripheral circulation as isolated elements. Working towards one common goal of optimizing systemic oxygen delivery and emphasizing anticipatory intensive care tailored to individual patients with the need for early, targeted investigation and intervention is essential when patients are not progressing as expected.

<![CDATA[Prone positioning in ARDS: physiology, evidence and challenges]]>

Introduction: Prone position has been used since the 1970s as a rescue therapy to treat severe hypoxemia in patients with acute respiratory distress syndrome (ARDS). Despite numerous observational and randomized controlled trials showing the effectiveness of prone position in improving oxygenation, mortality benefit was demonstrated only recently in the PROSEVA study1. Intensivists taking care of patients with ARDS should be aware about the physiological changes during prone ventilation, the latest evidence available and challenges that can be encountered in managing such patients. Physiology of prone position ventilation: When a person is supine, the weight of the ventral lungs, heart, and abdominal viscera increase dorsal pleural pressure. This compression reduces transpulmonary pressure in the dorsal lung regions. The increased mass of the edematous ARDS lung further increases the ventral-dorsal pleural pressure gradient and reduces regional ventilation of dependent dorsal regions. The ventral heart is estimated to contribute approximately an additional 3 to 5 cm of water pressure to the underlying lung tissue. In addition to the weight of the heart, intraabdominal pressure is preferentially transmitted through the diaphragm, further compressing dorsal regions. Although these factors tend to collapse dependent dorsal regions, the gravitational gradient in vascular pressures preferentially perfuses these regions, yielding a region of low ventilation and high perfusion, manifesting clinically as hypoxemia. Placing a person in the prone position reduces the pleural pressure gradient from nondependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity2[Figure 1]. Clinical evidence: A few large randomized clinical trials, conducted over a period of 15 years, investigated the possible benefit of prone position on ARDS outcome [Table 1]. The improvements in oxygenation apparent in most trials were not associated with improvements in mortality, suggesting that oxygenation is not itself the source of improved survival with prone positioning. Most recently, the PROSEVA study group1 enrolled 466 subjects with moderate-to-severe ARDS. Mortality at 28 and 90 days was significantly lower with prone position versus supine position (16% vs 33%, respectively, p < 0.001, and 24% vs 41%, respectively, p < 0.001). Challenges: There are only a few absolute contraindications to prone positioning, such as unstable vertebral fractures and unmonitored or significantly increased intracranial pressure. Hemodynamic instability and cardiac rhythm disturbances are some of the relative contraindications. The common complications of prone positioning are pressure ulcers, ventilator-associated pneumonia and endotracheal tube obstruction. More serious fatal events such as accidental extubation is rare (zero to 2.4% prevalence). A recent meta-analysis of the safety and efficacy of the maneuver showed that it is safe and inexpensive but requires teamwork and skill. Reports in the literature suggest that the incidence of adverse events is significantly reduced in the presence of trained and experienced staff. Thus, centers with less experience may have difficulty managing complications, but nursing care protocols and guidelines can mitigate this risk4. Conclusion: Prone position ventilation in patients with moderate-to-severe ARDS improves hypoxemia, provides mortality benefit and is relatively safe.

<![CDATA[Analgesic sparing effects of Dexmedetomidine in surgical intensive care patients]]>

Background: Dexmedetomidine (Dex) is a sedative agent with analgesic property.1,2 A recent review of the literature has shown clear advantages over the traditional sedation namely lesser respiratory depression, less delirium, better sedation, analgesia, organ protection and anti-shivering effect.3,4 Optimal sedation in critically ill patients is of vital importance, under sedation will raise work of breathing and causes adverse hemodynamic effects. Whereas over sedation will lead to increased number of imaging studies and higher morbidity and mortality.4,5 The aim of our study was to investigate the efficacy of dexmedetomidine (Dex), its use in intubated patients and post-extubation period, rescue sedation, safety and analgesic sparing effect in critically ill surgical patients. Patients and Methods: All patients sedated with dexmedetomidine (Dex) in the surgical intensive unit of a tertiary healthcare facility were included prospectively in the study. Patients' demographic data, diagnosis, surgical interventions, traditional sedation, Dex dosage and days, post-extubation Dex use, general adverse effects, adverse effects associated with lower or higher Dex doses, analgesic, and rescue sedation requirements were recorded. Patients were intubated and ventilated, the initial dose of Dex infusion was 0.5 mcg/kg/hr along with either fentanyl or remifentanil infusion. Dex infusion was titrated to keep the Ramsay sedation score of 3 to 4. Analgesia was titrated according to the NRS (numeric rating scale) in extubated patients and the Critical-Care Pain Observation Tool (CPOT) score in intubated patients. The infusion of fentanyl and remifentanil were titrated and decreased according to the CPOT score. Some of the patients extubated required continuation of the Dex infusion in the post-extubation period to maintain analgesia and to keep them calm.

Chi-square test was performed to compare among the groups. P-value ≤ 0.05 was considered as statistically significant. Results: A total of 428 patients were enrolled in the study. The majority of patients were male (73.3%). The most common diagnosis was acute abdomen and frequently the performed surgery was laparotomy (28.9%) (Figure 1a). The duration of Dex treatment ranged from 2 to 28 days; the most commonly used dose was 0.5 to 1.4 μg/kg/hours (Figure 1b). Seventy-eight percent (78%) of patients required Dex in the post-extubation period at a dose of 0.2 μg /kg/hours. There was significant reduction in the analgesic requirements in the post-Dex period (p < 0.001) (Table 1(a)). Adverse effects such as bradycardia 6.1%, hypertension 4% and hypotension 1.6% were observed (Figure 2) and there was no significant difference in lower and higher dose of Dex and occurrence of adverse effects (p < 0.82). Patients administered a higher dose of Dex required significantly higher rescue traditional sedation (p < 0.01) (Table 1(b)). Conclusion: We used dexmedetomidine in different surgical critical patients. The occurrence of adverse effects such as bradycardia, hypotension and hypertension were comparable to that mentioned in the literature. There was a significant analgesia sparing effect of dexmedetomidine. We continued Dex in the post-extubation period and the effective dose used was 0.2 mcg/kg/hour. There was no significant difference in occurrence of adverse effects with lower and higher range of Dex. The patients on a higher dose of Dex needed more rescue traditional sedation.

<![CDATA[Pre-hospital use of capnography during emergency sedation analgesia]]>

Background: Providing optimal patient care in the challenging, uncontrolled, and sometimes hostile pre-hospital environment may require the use of potent analgesics and sedatives. During pre-hospital emergencies, narcotics or sedatives administered for sedation, anxiolysis, or analgesia to allow the patient to tolerate unpleasant procedures, such as traction splint application, can result in cardiovascular and respiratory adverse events.1 Early recognition of poor oxygenation may prevent unnecessary patient hypoxia. The European Society of Anaesthesiology and the American Society of Anaesthesiologist mandate continuous capnography, in addition to standard monitoring which include pulse oximetry, 4-lead ECG, blood pressure, and heart rate measurements.1,2 Capnography refers to the non-invasive measurement of the partial pressure of carbon dioxide (CO2) in exhaled breath. Monitoring respiratory status provides early warning, thereby allowing clinicians to intervene before the onset of respiratory depression, potentially leading to bradypnoea, apnoea, hypoxia, and death.3 In addition, late identification of respiratory failure may lead to unnecessary endotracheal intubation and mechanical ventilation, increasing risk of protracted hospital stay and associated hospital-acquired infections.

Oxygenation and ventilation must be measured in both intubated and spontaneously breathing patients. While clinical indicators like chest rise or the plethysmography-derived respiratory rate can be used, monitoring the capnographic waveform for hypopnoeic and bradypnoeic patterns provides the clinician with a quick, accurate indication of acute adverse respiratory events.4 In two randomized trials, patients monitored with capnography in addition to standard of care, experienced significantly fewer episodes of hypoxia than those monitored without capnography.3,5 Hamad Medical Corporation Ambulance Service (HMCAS) in Qatar introduced a new clinical practice guideline (CPG) for safe sedation and monitoring in August 2017, mandating the routine use of capnography for all sedated patients. Safe sedation is achieved when the patient's oxygenation, ventilation, or haemodynamic status is not negatively impacted by the sedation procedure. Methods: The study aimed to describe trends in the use of capnography and other monitoring modalities for patients receiving Ketamine, Fentanyl, or Midazolam. Retrospective quantitative analysis of an existing HMCAS medical records database linked to a Business Intelligence (BI) tool enabled direct analysis on the tool and via a linked Microsoft Excel® spreadsheet, reviewing all emergency cases from 1st January 2017 to 31st December 2018. Frequency analysis and measures of central tendency was applied to the relevant clinical variables. All patient and practitioner identifiable data fields were redacted and not reported on. Results: Oxygen saturation (SpO2) and blood pressure monitoring was used on all patients (n = 5157, 100%), 4-lead ECG was placed on 3710 (72%) patients, while capnography was used on 4096 patients (79%, range = 39% to 99%). Capnography usage steadily improved over the 24-month period, especially for patients receiving Fentanyl (Figure 1). Conclusion: There was a significant improvement in the use of capnography during monitoring of patients that received Fentanyl, Ketamine, or Midazolam, with the most significant improvement for patients receiving Fentanyl alone. Further studies are required to determine the impact of this improvement on actual adverse event frequency.

<![CDATA[Hyponatremia induced compartment syndrome of all extremities: Case report and review]]>

Background: Compartment syndrome is a well-recognised complication from trauma, burns, orthopaedic, vascular, or other surgery of the limbs. Hyponatremia related rhabdomyolysis leading to compartment syndrome of all four extremities with renal and hepatic impairment is rare.1,2,3 Although the rhabdomyolysis can occur without hyponatremia. Young men have the highest incidence of compartment syndrome, particularly after long-bone extremity fractures and strenuous exercise.4,5 We present a case of compartment syndrome of all four extremities following a brief episode of recreational jogging. Case: A 39-year-old Indian male, known hypertensive on nifidipine and indapamide was presented to the emergency department with generalized weakness, lower leg pain and cramps for 3 days. He had jogged for 2 km in warm temperatures. His symptoms worsened and he was unable to walk. Other complaints were headache, pain in both arms, and passing dark coloured urine for two days. Both his calf muscles were tender, tense to feel, and painful on flexion and extension. Dorsalis pedis pulses were weak but palpable bilaterally. Capillary refill was less than three seconds and sensation were intact in both lower limbs. Oxygen saturation of toes on both feet was 99%. Other body systems were unremarkable. His respiratory rate was 20 min− 1, blood pressure 210/110 mmHg, temperature 36.6°C, oxygen saturation (SpO2) 99%. Initial biochemistry results were serum creatinine 142 umol.l− 1, myoglobin 5791− 1, creatinine phosphokinase 19032 U.l− 1, sodium: 124 mmol.l− 1, aspartate aminotransferase (AST) 167 U.l− 1, and alanine aminotransferase (ALT) 49 U.l− 1 (Table 1). Doppler ultrasound of leg vessels showed no evidence of deep venous thrombosis, echogenicity of the muscles in the thigh and lower leg appeared within normal limits. Rhabdomyolysis was diagnosed and rehydration begun with Hartman's solution 1000 ml followed by 125 ml.h− 1. The patient was admitted to the ward for continued hydration and analgesia to treat the pain. His leg pain worsened overnight despite intravenous analgesia. His pulse in both feet became feeble and renal and hepatic function worsened. Compartment syndrome was suspected and orthopaedic surgery was consulted. He had an emergency fasciotomy of all compartments and in all four limbs. Post-procedure pulse oximetry of digits and toes had a 99% saturation, but peripheral pulses remained weak. He was able to move fingers of both hands, but had no movement of his ankles and toes. The patient was transferred to the intensive care unit (ICU) for further management. His maintenance intravenous fluid was changed to 0.9% sodium chloride due to persistent hyponatremia. His wounds were re-explored and debrided on the fifth post-operative day. Wounds culture were growing pseudomonas aeruginosa that was treated with Meropenam according to the sensitivity. Six sittings of wound debridement and irrigation were performed. Over two weeks his renal function, liver function, and serum sodium concentration normalised (Table 1) without requiring renal replacement therapy. He was transferred to the ward on day 16 and discharged home to be followed in outpatient clinic. Conclusion: Physical exercise in the presence of hyponatremia can cause rhabdomyolysis and compartment syndrome of all extremities leading to multi-organ failure.

<![CDATA[Hyperglycemic hyperosmolar state causing multiple thrombosis]]>

Introduction: Diabetes mellitus is regarded as a pro-thrombotic state1. Extreme hyperglycemia and dehydration in the hyperglycemic hyperosmolar state (HHS) add to the risk for thrombo-ischemic events2,3. Lower limb ischemia and occlusion of the femoral arteries in HHS is a distinct association, but its development may be hard to recognize due to its infrequent occurrence in daily practice. Prompt recognition is important to prevent irreversible damage3,4,5. Case Presentation: A 50-year old female was admitted to the intensive care unit (ICU) with epigastric pain for 1 day. She reported no other medical conditions except hypertension. Clinical examination showed a fully conscious female who was severely dehydrated. Clinical and laboratory parameters on admission are represented in Table 1. Based on a glucose level >30 mmol/L and an osmolarity >320 mOsm/L, HHS was diagnosed. Other investigations (septic work up, chest X ray, and ECG) were normal. The patient received a total of 9 liters of 0.9% saline with insulin/potassium over 6 hours. Dalteparin was given subcutaneously (5000 IU daily). On the second day of admission signs of acute ischemia were noticed in the left upper and left lower limbs. An ultrasound doppler and CT angiography confirmed the occlusion of the left subclavian, left femoral artery and aortic arch thrombosis (Figures 1A). Echocardiography showed a thrombus in the aortic arch. An emergency thrombectomy of the brachial and femoral arteries and a left arm fasciotomy took place and therapeutic unfractionated heparin infusion was started. A thrombophilia work up for antiphospholipid syndrome, heparin induced thrombocytopenia, complements 3 and 5, antinuclear antibody (ANCA), lupus screen, homocysteine, antithrombin, Factor V leiden, anticardiolipin, anti-B2 glycoprotein, protein S and C activity were normal. The patient and the family denied a personal or family history of thromboembolic events. On the fifth day post-admission, the patient developed septic shock with multi-organ failure (circulatory, respiratory, renal, and coagulation). The patient responded to ICU management. Parameters of her coagulation profile are given in Table 1. On the ninth day the patient developed dry gangrene in the left foot, which required a below the knee amputation. On the eleventh day the patient was extubated, neurological assessment was showing right-sided hemiparesis. The MRI was showing multiple microcerebral hemorrhages, an infarction in the left paramedian pons and a cerebellar infarction (Figures 1B). On the fourteenth day the patient developed abdominal distension. The CT showed partial mesenteric vein thrombosis despite the patient being on therapeutic heparin (Figure 2). On the seventeenth day the patient had a tracheostomy and was discharged from the ICU for rehabilitation on a therapeutic dose of dalteparin. Conclusion: Current guidelines provide for thromboprophylaxis in HHS, i.e., heparin during admission. This covers the risk for deep venous thrombosis (DVT), but might be insufficient in case of an imminent arterial thrombosis, especially in cases of long existing diabetes.

Alternative therapy targeting crucial factors in the coagulation pathway leading to an arterial thrombus should be searched. The development of an algorithm for thromboprophylaxis in a hyperglycemic crisis needs our attention to improve the outcome of this high-risk condition.

<![CDATA[Bridging the gap: Improving patient safety through targeted in-situ simulation training in a paediatric intensive care unit and Learning from Excellence (LfE)]]>

Background: Improving patient safety and reducing risk is important to a Paediatric Intensive Care Unit (PICU). Simulation-based education has generally focused on the management of clinical diagnoses, whereas the Quality and Safety Team has traditionally focused on collecting and analysing data about adverse events. There is a need to bridge the gap between the two streams - lessons learnt from adverse incidents and their impartation to staff in a targeted format during in-situ simulation training.

Methods: Birmingham Children's Hospital PICU is a 31-bedded tertiary/quaternary unit with approximately 1500 admissions per year in the UK. All adverse incidents are collated (online IR1 with specific forms for incidents involving medications, accidental extubations, buzzer pulls, and extravasations) and analysed by the PICU Safety Group and trends are monitored. The PICU Simulation Team delivers in-situ simulation training for the multidisciplinary PICU staff weekly using interactive, computer-controlled manikins. Each training scenario and debriefing lasts 1 hour. A core team of multidisciplinary simulation facilitators runs the simulation training and the AI (advocacy-inquiry) debriefing model1 is used for conducting the debriefings. The ‘Simulation Group’ (efferent) and the ‘Risk Group’ (afferent) regularly discuss the priorities for the unit and the lessons learnt based on actual events or near-misses in the unit. It then implements the action points during targeted scenario training sessions. This may be the utilisation of a care bundle or activation of a ‘clinical pathway’. Any practical problem with implementation of these policies is fed back to the Risk Group to close the loop. A concept of ‘Learning from Excellence’ (LfE) has been introduced successfully and both ‘adverse incidents’ and LfE are used together as approaches to improve patient safety in the unit.

Observation/Evaluation: Various simulation scenarios have been run since the start of the project. Examples include accidental extubations, delay in sepsis recognition and antibiotics prescription, ischaemic limb injury due to the indwelling arterial line, emergency chest reopening in post-operative cardiac surgical patients, child protection and safeguarding2. The learning gained during each debriefing is generalised to all the participants of the simulation session3 and then subsequently the salient points are shared by email with the entire unit. All staff members have to undergo simulation training. Scenarios are re-run back to back if the team does not achieve the expected outcomes. The anonymous feedback forms completed by the participants of the scenarios have shown they value this targeted training and that it has helped them implement good practice. Anecdotaly, the trend of ‘incident severity’ is believed to have been on the decline over a 7-year period in our PICU but long term monitoring will continue to identify any re-emerging or fresh trends.

Conclusion: ‘Targeted’ simulation-based training is an important approach to enhance the safety culture in PICU. PICU Safety and Simulation Groups should develop a symbiotic relationship for this to succeed. Learning from Excellence can be effectively utilised to embed good practice in a clinical area.

<![CDATA[Factors contributing to patients’ presentation to the emergency department of an academic hospital in Oman after leaving other hospitals against medical advice]]>

Background: One of the reasons to leave against medical advice (LAMA) from a hospital is to seek treatment in another hospital1. Those patients are at high risk of readmission and mortality compared to patients with planned discharge2. The aim of this study was to identify the factors for patients' presentations to an academic tertiary hospital Emergency Department (ED) specifically after LAMA from another hospital and to investigate the outcomes of these presentations. Methods: We conducted a prospective cross-sectional study. We included all patients who presented to Sultan Qaboos University Hospital (SQUH) ED after LAMA from other hospitals in Oman during the six-month study period. We excluded patients who died during hospitalization, those who refused to give consent, and those who were identified only after their ED visits' by reviewing the ED medical records' and were difficult to be contacted. We asked the participants to fill a paper-based questionnaire to investigate the factors of their presentations to SQUH ED. We designed the questionnaire by reviewing the literature on second opinion, patient's satisfaction, and LAMA35. The questionnaire underwent a content validation by two experts. We investigated the outcomes of the presentations by reviewing the patients' medical charts. We used descriptive statistics to analyse the data. Results: A total of 112 patients presented to SQUH ED after LAMA from other hospitals. 94 of them participated, while 18 patients were excluded. There was equal male to female distribution among the participants and their mean age was 36.8 years (SD = 26.483). Figure 1 illustrates the previous hospitals where patients LAMA. The majority of patients (66.0%) were LAMA from governorate hospitals. Table 1 presents the factors of presentation to SQUH ED. The most common factor to present to SQUH ED (94.7%) was to get the quality of care delivered in SQUH. Out of 94 patients, 70 (74.5%) were admitted to SQUH. More than one-third of the admitted patients (35.7%) required management in critical care units. Conclusion: This study provides the factors that lead LAMA patients to choose an academic tertiary hospital for their second presentation. Identifying these factors can help the decision makers in the healthcare system in Oman to increase the quality of services in other healthcare facilities. Providing more healthcare facilities with diagnostic modalities like Magnetic Resonance Imaging (MRI) and in some places even Computed Tomography (CT) imaging may help decrease the incidence of LAMA. Also considering the addition of diagnostic and therapeutic units (for example: endoscopic suites and angiography suites) may allow for better health services in these hospitals and therefore minimize the occurrence of LAMA. Furthermore, allowing for and addressing the need for second opinion in some patients and organizing for that formally between different specialties in these hospitals may improve the patient satisfaction and therefore reduce the incidence of LAMA. Ultimately all the previously mentioned interventions can minimize the morbidity and mortality associated with LAMA. The study can also act as a pilot for larger multicentered studies.

<![CDATA[Portable respiratory polygraphy monitoring of obese mothers the first night after caesarean section with bupivacaine/morphine/fentanyl spinal anaesthesia]]>

Background: Obesity, abdominal surgery, and intrathecal opioids are all factors associated with a risk for respiratory compromise. The aim of this explorative trial was to study the apnoea/hypopnea index 1st postoperative night in obese mothers having had caesarean section (CS) in spinal anaesthesia with a combination of bupivacaine/morphine and fentanyl.

Methods: Consecutive obese (BMI >30 kg/m 2) mothers, ≥18 years, scheduled for CS with bupivacaine/morphine/fentanyl spinal anaesthesia were monitored with a portable polygraphy device Embletta /NOX on 1 st postoperative night. The apnoea/hypopnea index (AHI) was identified by clinical algorithm and assessed in accordance to general guidelines; number of apnoea/hypopnea episodes per hour: <5 “normal”, ≥5 and <15 mild sleep apnoea, ≥15 and <30 moderate sleep apnoea, ≥ 30 severe sleep apnoea. Oxygen desaturation events were in similar manner calculated per hour as oxygen desaturation index (ODI).

Results: Forty mothers were invited to participate: 27 consented, 23 were included, but polysomnography registration failed in 3. Among the 20 mothers studied: 11 had an AHI <5 ( normal), 7 mothers had AHI ≥5 but <15 ( mild OSAS) and 2 mothers had AHI ≥15 ( moderate OSA), none had an AHI ≥ 30. The ODI was on average 4.4, and eight patients had an ODI >5. Mothers with a high AHI (15.3 and 18.2) did not show high ODI. Mean saturation was 94% (91-96%), and four mothers had mean SpO 2 90-94%, none had a mean SpO2 <90%.

Conclusion: Respiratory polygraphy 1 st night after caesarean section in spinal anaesthesia with morphine in moderately obese mothers showed AHIs that in sleep medicine terms are considered normal, mild and moderate. Obstructive events and episodes of desaturation were commonly not synchronised. Further studies looking at preoperative screening for sleep apnoea in obese mothers are warranted but early postop respiratory polygraphy recording is cumbersome and provided sparse important information.

<![CDATA[Bi-Level ventilation decreases pulmonary shunt and modulates neuroinflammation in a cardiopulmonary resuscitation model]]>


Optimal ventilation strategies during cardiopulmonary resuscitation are still heavily debated and poorly understood. So far, no convincing evidence could be presented in favour of outcome relevance and necessity of specific ventilation patterns. In recent years, alternative models to the guideline-based intermittent positive pressure ventilation (IPPV) have been proposed. In this randomized controlled trial, we evaluated a bi-level ventilation approach in a porcine model to assess possible physiological advantages for the pulmonary system as well as resulting changes in neuroinflammation compared to standard measures.


Sixteen male German landrace pigs were anesthetized and instrumented with arterial and venous catheters. Ventricular fibrillation was induced and the animals were left untreated and without ventilation for 4 minutes. After randomization, the animals were assigned to either the guideline-based group (IPPV, tidal volume 8–10 ml/kg, respiratory rate 10/min, FiO21.0) or the bi-level group (inspiratory pressure levels 15–17 cmH2O/5cmH2O, respiratory rate 10/min, FiO21.0). Mechanical chest compressions and interventional ventilation were initiated and after 5 minutes, blood samples, including ventilation/perfusion measurements via multiple inert gas elimination technique, were taken. After 8 minutes, advanced life support including adrenaline administration and defibrillations were started for up to 4 cycles. Animals achieving ROSC were monitored for 6 hours and lungs and brain tissue were harvested for further analyses.


Five of the IPPV and four of the bi-level animals achieved ROSC. While there were no significant differences in gas exchange or hemodynamic values, bi-level treated animals showed less pulmonary shunt directly after ROSC and a tendency to lower inspiratory pressures during CPR. Additionally, cytokine expression of tumour necrosis factor alpha was significantly reduced in hippocampal tissue compared to IPPV animals.


Bi-level ventilation with a constant positive end expiratory pressure and pressure-controlled ventilation is not inferior in terms of oxygenation and decarboxylation when compared to guideline-based IPPV ventilation. Additionally, bi-level ventilation showed signs for a potentially ameliorated neurological outcome as well as less pulmonary shunt following experimental resuscitation. Given the restrictions of the animal model, these advantages should be further examined.

<![CDATA[Stepwise stroke recognition through clinical information, vital signs, and initial labs (CIVIL): Electronic health record-based observational cohort study]]>


Stroke recognition systems have been developed to reduce time delays, however, a comprehensive triaging score identifying stroke subtypes is needed to guide appropriate management. We aimed to develop a prehospital scoring system for rapid stroke recognition and identify stroke subtype simultaneously.

Methods and findings

In prospective database of regional emergency and stroke center, Clinical Information, Vital signs, and Initial Labs (CIVIL) of 1,599 patients suspected of acute stroke was analyzed from an automatically-stored electronic health record. Final confirmation was performed with neuroimaging. Using multiple regression analyses, we determined independent predictors of tier 1 (true-stroke or not), tier 2 (hemorrhagic stroke or not), and tier 3 (emergent large vessel occlusion [ELVO] or not). The diagnostic performance of the stepwise CIVIL scoring system was investigated using internal validation. A new scoring system characterized by a stepwise clinical assessment has been developed in three tiers. Tier 1: Seven CIVIL-AS3A2P items (total score from –7 to +6) were deduced for true stroke as Age (≥ 60 years); Stroke risks without Seizure or psychiatric disease, extreme Sugar; “any Asymmetry”, “not Ambulating”; abnormal blood Pressure at a cut-off point ≥ 1 with diagnostic sensitivity of 82.1%, specificity of 56.4%. Tier 2: Four items for hemorrhagic stroke were identified as the CIVIL-MAPS indicating Mental change, Age below 60 years, high blood Pressure, no Stroke risks with cut-point ≥ 2 (sensitivity 47.5%, specificity 85.4%). Tier 3: For ELVO diagnosis: we applied with CIVIL-GFAST items (Gaze, Face, Arm, Speech) with cut-point ≥ 3 (sensitivity 66.5%, specificity 79.8%). The main limitation of this study is its retrospective nature and require a prospective validation of the CIVIL scoring system.


The CIVIL score is a comprehensive and versatile system that recognizes strokes and identifies the stroke subtype simultaneously.

<![CDATA[Association of weaning preparedness with extubation outcome of mechanically ventilated patients in medical intensive care units: a retrospective analysis]]>


Assessment of preparedness of weaning has been recommended before extubation for mechanically ventilated patients. We aimed to understand the association of a structured assessment of weaning preparedness with successful liberation.


We retrospectively investigated patients with acute respiratory failure who experienced an extubation trial at the medical intensive care units of a medical center and compared the demographic and clinical characteristics between those patients with successful and failed extubation. A composite score to assess the preparedness of weaning, the WEANSNOW score, was generated consisting of eight components, including Weaning parameters, Endotracheal tube, Arterial blood gas analysis, Nutrition, Secretions, Neuromuscular-affecting agents, Obstructive airway problems and Wakefulness. The prognostic ability of the WEANSNOW score for extubation was then analyzed.


Of the 205 patients included, 138 (67.3%) patients had successful extubation. Compared with the failure group, the success group had a significantly shorter duration of MV before the weaning attempt (11.2 ± 11.6 vs. 31.7 ± 26.2 days, p < 0.001), more with congestive heart failure (42.0% vs. 25.4%, p = 0.020), and had different distribution of the types of acute respiratory failure (p = 0.037). The failure group also had a higher WEANSNOW score (1.22 ± 0.85 vs. 0.51 ± 0.71, p < 0.001) and worse Rapid Shallow Breathing Index (93.9 ± 63.8 vs. 56.3 ± 35.1, p < 0.001). Multivariate logistic regression analysis showed that a WEANSNOW Score = 1 or higher (OR = 2.880 (95% CI [1.291–6.426]), p = 0.010) and intubation duration >21 days (OR = 7.752 (95% CI [3.560–16.879]), p < 0.001) were independently associated with an increased probability of extubation failure.


Assessing the pre-extubation status of intubated patients in a checklist-based approach using the WEANSNOW score might provide valuable insights into extubation failure in patients in a medical ICU for acute respiratory failure. Further prospective studies are warranted to elucidate the practice of assessing weaning preparedness.

<![CDATA[Association between boarding in the emergency department and in-hospital mortality: A systematic review]]>


Boarding in the emergency department (ED) is a critical indicator of quality of care for hospitals. It is defined as the time between the admission decision and departure from the ED. As a result of boarding, patients stay in the ED until inpatient beds are available; moreover, boarding is associated with various adverse events.

Study objective

The objective of our systematic review was to determine whether ED boarding (EDB) time is associated with in-hospital mortality (IHM).


A systematic search was conducted in academic databases to identify relevant studies. Medline, PubMed, Scopus, Embase, Cochrane, Web of Science, Cochrane, CINAHL and PsychInfo were searched. We included all peer-reviewed published studies from all previous years until November 2018. Studies performed in the ED and focused on the association between EDB and IHM as the primary objective were included. Extracted data included study characteristics, prognostic factors, outcomes, and IHM. A search update in PubMed was performed in May 2019 to ensure the inclusion of recent studies before publishing.


From the initial 4,321 references found through the systematic search, the manual screening of reference lists and the updated search in PubMed, a total of 12 studies were identified as eligible for a descriptive analysis. Overall, six studies found an association between EDB and IHM, while five studies showed no association. The last remaining study included both ICU and non-ICU subgroups and showed conflicting results, with a positive association for non-ICU patients but no association for ICU patients. Overall, a tendency toward an association between EDB and IHM using the pool random effect was observed.


Our systematic review did not find a strong evidence for the association between ED boarding and IHM but there is a tendency toward this association. Further well-controlled, international multicenter studies are needed to demonstrate whether this association exists and whether there is a specific EDB time cut-off that results in increased IHM.