Vol 5 No 3 (2019): Summer
Feasibility of Routine Data Collection on Intensive Care Unit Performance and Activity in Resource Limited Settings
Background: Routine collection and analysis of data allows a critical care department to highlight the outcomes of the interventions done and to identify the grounds for improvement. Data on characteristic and outcomes of patients admitted in intensive care units (ICUs) are lacking.
Methods: A software (ICU e-monitoring®) was designed to enter for each patient demographic data, SAPS3 on admission, Nine Equivalent Manpower Use Score, presence of medical devices and episodes of hospital acquired infections. We report data collected during 2014 with comparison to data collected with the same methodology in 2008 .
Objective: To determine the standardized mortality ratio, the mean length of ICU stay, mean length of mechanical ventilation and ICU acquired infection incidence rate.
Study design: Descriptive
Place of study: Medical ICU, Pakistan Institute of Medical Sciences Islamabad
Results: A total of 196 admissions were recorded during the year 2014 vs 354 in 2008. 47.2% were males and 52.8% were females. Mean age was 32.1 years ± 15.3 SD (37.7 ± 18.9 SD in 2008). A total of 65 (33%) deaths were recorded during the year and standardized mortality ratio was found to be 0.71 vs 1.09 in 2008. Mean Length of stay was 15.9 Days ± 12.9 SD (9.3 days ± 8.9 in 2008) and mean duration of mechanical ventilation was found to be 12.04 Days (8.7 in 2008). Overall ventilator associated pneumonia (VAP) rate was 42.3 cases per 1000 ventilator days. Rate of Catheter Related Blood Stream Infections (CRBSI) was found to be 17.2 cases per 1000 CVC days.
Conclusion: Major changes in our patient population characteristics were seen between 2008 and 2013: number of patients and standardized mortality was decreased while incidence of VAP and CRBSI was increased. It is possible to collect meaningful data on ICU performance and activity in resource limited settings.
Correlation between Serum Vancomycin Trough Level and Therapeutic Response in Septic Patients during Augmented Renal Clearance Phase
Background: Vancomycin is a glycopeptide antibiotic that was extensively used for treatment of gram positive infections. Therapeutic drug monitoring (TDM) is recommended to optimize efficacy and safety of vancomycin. Data regarding TDM of vancomycin are scant in septic patients especially during augmented renal clearance (ARC) phase.
Methods: In this observational study, 39 patients with diagnosis of sepsis that were in ARC phase were evaluated. The breakpoint for serum trough level of vancomycin was considered as 15 mg/l. The patients were stratified in two groups based on the measured serum trough levels (< 15 mg/l versus ≥15 mg/l).
Results: Clinical response and microbiological clearance were compared between the groups. In terms of clinical response, there was no significant difference between the groups (P = 0.677). Also, the microbiological clearance was not different between the groups (P= 1.00).
Conclusion: Septic patients during ARC phase had comparable clinical and microbial responses regardless of serum trough levels of vancomycin.
Comparison of Effectiveness and Side Effects of Diazepam versus Midazolam Administration for Conscious Sedation in Patients Who Underwent Cataract Surgery
Background: The purpose of this study was to compare the effectiveness and side effects of diazepam and midazolam administration for conscious sedation in subjects who undergoing cataract surgery.
Methods: A total of 79 patients undergoing cataract surgery under topical anesthesia with conscious sedation were prospectively reviewed. Our subjects were randomly divided to two groups. The first group comprised of 38 cases receiving 0.05 mg/kg diazepam slow intravenously (diazepam group) and the second group comprised of 41 cases receiving 0.01 mg/kg midazolam intravenously (midazolam group). Intraoperative variables such as systolic and diastolic arterial pressure, heart rate, respiratory rate and blood oxygen saturation were recorded immediately before sedation, 5, 10 and 15 minutes after diazepam or midazolam administration. All patients were contacted 24 hours after the operation for any early postoperative complications.
Results: The variability of systolic and diastolic blood pressure at 5, 10 and 15 minutes after sedation were statistically significantly higher in midazolam group compared to diazepam group. Six patients developed episodes of apnea during operation, two patients in diazepam and four patients in midazolam group. The surgeons’ satisfaction was more in diazepam group but not statistically significant. Need for additional dose of benzodiazepine was more in the midazolam group. Drowsiness and functional impairment during 24 hours after surgery were not significantly different between the two groups.
Conclusion: Diazepam produces better perioperative hemodynamic profile, level of sedation and surgeon’s satisfaction and less occurrence of apnea compared to midazolam group in patients who underwent cataract surgery.
Correlation between Serum Magnesium and Lactate Levels at the Time of ICU Admission and Early Phase of Sepsis
Background: As the fourth abundant electrolyte in the body, magnesium has critical roles in aerobic metabolism and regulation of the immune system. Few studies investigate the association between magnesium status of critically ill septic patients and lactate acidosis in the intensive care unit (ICU). In this study, serum magnesium level and lactate level were evaluated at both admission time and time of sepsis.
Methods: This was a prospective, cross-sectional study conducted at general ICU of a tertiary referral teaching hospital. Hypomagnesemia was defined as a serum magnesium concentration of less than 1.7 mg/dL. Mann-Whitney test and independent-sample t-test were used to analyze nonparametric and parametric data, respectively.
Results: Of 50 sepsis patients, 32 patients were normomagnesemic, and 18 were hypomagnesemic. Hypomagnesemic patients have significantly higher lactate serum level at the time of sepsis compared to normomagnesemic patients [2.32 (1.96-3.29) vs. 1.94 (1.80-2.15) mg/dl respectively, p<0.001]. There were significant differences between normomagnesemic and hypomagnesemic septic patients in Acute Physiology and Chronic Health Evaluation (APACHE) II score at sepsis time (9.44 ± 4.33 vs. 11.67 ± 3.83, p=0.46), and Sequential Organ Failure Assessment (SOFA) score [3 (3.00-5.00) vs. 4 (3.75-6.25), p=0.04]. Also, 28-day mortality because of sepsis (50% respectively, p<0.001), duration of mechanical ventilation [12.00 (4.00-14.25) days respectively, p<0.01] and ICU stay [14.00 (12.75-17.25) days respectively, p<0.01] were significantly higher in hypomagnesemic groups.
Conclusion: Admission hypomagnesemia in sepsis patients may increase serum lactate concentration, duration of ventilation, duration of ICU stay and mortality.
Effects of Ringer Lactate Normal Saline Combination versus Normal Saline during Renal Transplantation Surgery on Early Postoperative Outcome
Background: Traditionally normal saline is the most common crystalloid solution that is used in transplant surgery. Normal saline (NS) because of the higher risk of acidosis and higher levels of serum chloride may have more deleterious effects in kidney transplant recipients Thus; the aim of this study was to determine the safety of ringer lactate normal saline combination if used during a renal transplant.
Methods: One Hundred adults undergoing kidney transplantations were enrolled in a double-blinded randomized prospective clinical trial. They were divided into two groups in order to receive RL& NS and NS infusion as intraoperative IV fluid replacement therapy. All patients received 40 ml/kg fluid during surgery. Serum chloride, sodium, Cr and BUN were checked before operation and 6hour after surgery. Urine output BUN and Cr was also checked in 1, 3 and 7 day after surgery. At the end of surgery, we corrected the acid base status with bicarbonate according to base excess< -15 or PH<7.15 if needed in both groups.
Results: There was a significant difference in the serum chloride level (p= 0.001) and urine output (p= 0.003) between the two groups at the 6 hours after transplantations. Postoperative BUN and Cr level at 2,3 and 7 days in RL&NS group was significantly lower than group of NS (P= 0.011). Also, urine output during this study time was significantly higher in RL&NS group (p=0.001).
Conclusion: Combination of Ringer lactate &normal saline crystalloid solutions are associated with higher urinary output and most favorited out come in the early post-operative days after renal transplantation surgeries.
Effect of Single Dose of Pregabalin on Post Tracheal Intubation Sore Throat after General Anesthesia
Background: Sore throat is one of the major complications of tracheal intubation after general anesthesia. Pregabalin is an analgesic, the anti neuropathic pain and analgesic effects of which have been demonstrated in various studies. This study examined the effects of single dose pregabalin one hour before tracheal intubation, to prevent sore throat after extubation.
Methods: In a double-blind, randomized clinical trial, 60 patients who had undergone general and urologic surgeries at Imam Reza hospital in Tabriz, Iran, since March to July 2015 that required tracheal intubation, were included in the study. The patients were randomly divided into two groups (group A, 30 patients and group B, 30 patients). In the group A, an hour before anesthesia, one pregabalin tablet (300mg) was given to the patients. For the patients of the group B, the placebo was given. After awareness of patients, the severity of sore throat was measured and recorded by VAS scale after 2, 6 and 24 hours of the surgery.
Results: Severity and incidence of sore throat after tracheal intubation were not significantly different between two groups. Meanwhile, no side effects of pregabalin were observed in the group A.
Conclusion: Administration of pregabalin as a single dose of 300 mg one hour prior to anesthesia and intubation decreased the incidence and severity of sore throat in the case group than the control group, although the amount of this reduction was not statistically significant between the two groups.
Therapeutic Effects of Ursodeoxycholic Acid in Neonatal Indirect Hyperbilirubinemia: A Randomized Double-blind Clinical Trial
Background: Ursodeoxycholic acid (UDCA) is a safe drug used in the treatment of cholestatic liver disorders in children. The aim of this study was to investigate the synergistic effect of UDCA in combination with phototherapy in treating indirect neonatal hyperbilirubinemia.
Methods: Present double-blinded, randomized clinical trial was conducted among neonates with jaundice who were under treatment with phototherapy in the neonatal ward affiliated with the Zabol University of Medical Sciences in 2017. The patients (200 neonates) were randomly divided into intervention (phototherapy+ UDCA) and control (phototherapy alone) groups. The intervention group received 15 mg/kg UDCA daily.
Results: Total bilirubin levels at birth, 24, 48, and 72 hours after therapy were 16.89± 2.49, 14.28± 2.05, 11.62± 2.46, and 10.26± 1.92 mg/dl in controls and 15.79± 2.18, 12.77± 1.86, 10.08± 1.66, and 8.94± 1.38 mg/dl in intervention group respectively (P< 0.001). The ratio of neonates with total bilirubin< 10 mg/dl were 28% and 55% after 48 hours, and 64% and 90% after 72 hours of therapy initiation in phototherapy alone and phototherapy+ UDCA groups respectively (P< 0.001). The mean reduction of direct bilirubin was not significantly different between the groups.
Conclusion: UDCA was effective in accelerating reduction of total bilirubin level in neonates with unconjugated hyperbilirubinemia under phototherapy but had no effect on direct bilirubin levels.
Cardiac arrhythmias during anesthesia are common and almost benign, with the incidence ranging from 60 to 90%. Arrhythmias are one of several significant predictors for severe cardiovascular outcomes. It is essential, therefore, for the anesthetist to evaluate patients at risk preoperatively with a careful history and to have an appropriate knowledge concerning the etiology, electrophysiology, diagnosis, drug effects and treatment of arrhythmias.
Central venous catheter (CVC) insertion is a common procedure in operation theaters and intensive care units (ICU). The procedure is performed through anatomical landmark technique, open surgical procedure, and ultrasound-assisted insertion. In the 1990s, ultrasound guidance of CVC insertion has been advocated as a means to reduce mechanical complications and placement failures compared with the landmark technique. Still CVC complications can be related to insertion, indwelling, or extraction. There is a need for continuous monitoring to avoid possible risk factors so as to minimize the morbidity and mortality.