1
|
Tsonas AM, van Meenen DM, Botta M, Shrestha GS, Roca O, Paulus F, Neto AS, Schultz MJ. Hyperoxemia in invasively ventilated COVID-19 patients-Insights from the PRoVENT-COVID study. Pulmonology 2024; 30:272-281. [PMID: 36274046 PMCID: PMC10155497 DOI: 10.1016/j.pulmoe.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/29/2022] [Accepted: 09/01/2022] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE We determined the prevalences of hyperoxemia and excessive oxygen use, and the epidemiology, ventilation characteristics and outcomes associated with hyperoxemia in invasively ventilated patients with coronavirus disease 2019 (COVID-19). METHODS Post hoc analysis of a national, multicentre, observational study in 22 ICUs. Patients were classified in the first two days of invasive ventilation as 'hyperoxemic' or 'normoxemic'. The co-primary endpoints were prevalence of hyperoxemia (PaO2 > 90 mmHg) and prevalence of excessive oxygen use (FiO2 ≥ 60% while PaO2 > 90 mmHg or SpO2 > 92%). Secondary endpoints included ventilator settings and ventilation parameters, duration of ventilation, length of stay (LOS) in ICU and hospital, and mortality in ICU, hospital, and at day 28 and 90. We used propensity matching to control for observed confounding factors that may influence endpoints. RESULTS Of 851 COVID-19 patients, 225 (26.4%) were classified as hyperoxemic. Excessive oxygen use occurred in 385 (45.2%) patients. Acute respiratory distress syndrome (ARDS) severity was lowest in hyperoxemic patients. Hyperoxemic patients were ventilated with higher positive end-expiratory pressure (PEEP), while rescue therapies for hypoxemia were applied more often in normoxemic patients. Neither in the unmatched nor in the matched analysis were there differences between hyperoxemic and normoxemic patients with regard to any of the clinical outcomes. CONCLUSION In this cohort of invasively ventilated COVID-19 patients, hyperoxemia occurred often and so did excessive oxygen use. The main differences between hyperoxemic and normoxemic patients were ARDS severity and use of PEEP. Clinical outcomes were not different between hyperoxemic and normoxemic patients.
Collapse
Affiliation(s)
- A M Tsonas
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands.
| | - D M van Meenen
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - M Botta
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands
| | - G S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - O Roca
- Department of Intensive Care, Vall d'Hebron Univerity Hospital, Barcelona, Spain; Ciber Enfermedades Respiratorias (CibeRes), Instituto de Salud Carlos III, Madrid, Spain
| | - F Paulus
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands; ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Faculty of Health, Amsterdam, The Netherlands
| | - A S Neto
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia; Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - M J Schultz
- Department of Intensive Care, Amsterdam UMC, location 'AMC', Amsterdam, The Netherlands; Department of Critical Care Medicine, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
2
|
Bartlett ES, Lim A, Kivlehan S, Losonczy LI, Murthy S, Lowsby R, Papali A, Raees M, Seth B, Cobb N, Brotherton J, Dippenaar E, Nepal G, Shrestha GS, Kuo SCE, Skrabal JR, Davis M, Lay C, Yi S, Jaung M, Chaffay B, Sefa N, Yang ML, Stephens PA, Rashed A, Benzoni N, Velasco B, Adhikari NK, Reynolds T. Critical care delivery across health care systems in low-income and low-middle-income country settings: A systematic review. J Glob Health 2023; 13:04141. [PMID: 38033248 PMCID: PMC10691174 DOI: 10.7189/jogh.13.04141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Background Prior research has demonstrated that low- and low-middle-income countries (LLMICs) bear a higher burden of critical illness and have a higher rate of mortality from critical illness than high-income countries (HICs). There is a pressing need for improved critical care delivery in LLMICs to reduce this inequity. This systematic review aimed to characterise the range of critical care interventions and services delivered within LLMIC health care systems as reported in the literature. Methods A search strategy using terms related to critical care in LLMICs was implemented in multiple databases. We included English language articles with human subjects describing at least one critical care intervention or service in an LLMIC setting published between 1 January 2008 and 1 January 2020. Results A total of 1620 studies met the inclusion criteria. Among the included studies, 45% of studies reported on pediatric patients, 43% on adults, 23% on infants, 8.9% on geriatric patients and 4.2% on maternal patients. Most of the care described (94%) was delivered in-hospital, with the remainder (6.2%) taking place in out-of-hospital care settings. Overall, 49% of critical care described was delivered outside of a designated intensive care unit. Specialist physicians delivered critical care in 60% of the included studies. Additional critical care was delivered by general physicians (40%), as well as specialist physician trainees (22%), pharmacists (16%), advanced nursing or midlevel practitioners (8.9%), ambulance providers (3.3%) and respiratory therapists (3.1%). Conclusions This review represents a comprehensive synthesis of critical care delivery in LLMIC settings. Approximately 50% of critical care interventions and services were delivered outside of a designated intensive care unit. Specialist physicians were the most common health care professionals involved in care delivery in the included studies, however generalist physicians were commonly reported to provide critical care interventions and services. This study additionally characterised the quality of the published evidence guiding critical care practice in LLMICs, demonstrating a paucity of interventional and cost-effectiveness studies. Future research is needed to understand better how to optimise critical care interventions, services, care delivery and costs in these settings. Registration PROSPERO CRD42019146802.
Collapse
Affiliation(s)
- Emily S Bartlett
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrew Lim
- Section of Critical Care Medicine, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Sean Kivlehan
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Humanitarian Initiative, Cambridge, Massachuesetts, USA
| | - Lia I Losonczy
- Department of Emergency Medicine, Department of Anaesthesia and Critical Care Medicine, George Washington University Medical Center, Washington, District of Columbia, USA
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Lowsby
- Department of Critical Care Medicine, Department of Emergency Medicine, Mid Cheshire Hospitals National health Service Foundation Trust, Cheshire, UK
| | - Alfred Papali
- Pulmonary and Critical Care Medicine, Atrium Health, Pineville, North Carolina, USA
| | - Madiha Raees
- Division of Critical Care Medicine, Department of Anaesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Bhavna Seth
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Natalie Cobb
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Jason Brotherton
- Department of Internal Medicine and Paediatrics, Africa Inland Church Kijabe Hospital, Kijabe Kenya
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Gaurav Nepal
- Ministry of Health and Population, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Shih-Chiang E Kuo
- The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Ryan Skrabal
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Margaret Davis
- Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
| | - Cappi Lay
- Department of Neurosurgery, Department of Emergency Medicine, The Mount Sinai Hospital, New York, New York, USA
| | - Sojung Yi
- Stanford University, Stanford, California, USA
| | - Michael Jaung
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brandon Chaffay
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia, USA
| | - Nana Sefa
- Department of Emergency Medicine, Department of Critical Care, Medstar Washington Hospital Center, Washington, District of Columbia, USA
| | - Marc Lc Yang
- Accident and Emergency Medicine, The Chinese University of Hong Kong Faculty of Medicine, Hong Kong
| | - P Andrew Stephens
- Department of Emergency Medicine, Intensive Care & Resuscitation, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amir Rashed
- Albert Einstein College of Medicine, New York, New York, USA
| | - Nicole Benzoni
- Critical Care Medicine, Virginia Mason Franciscan Health, Silverdale, Washington, USA
| | - Bernadett Velasco
- Department of Emergency Medicine, East Avenue Medical Center, Quezon City, National Capital Region, Philippines
| | - Neill Kj Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| |
Collapse
|
3
|
Sodhi K, Chanchalani G, Arya M, Shrestha GS, Chandwani JN, Kumar M, Kansal MG, Ashrafuzzaman M, Mudalige AD, Al Tayar A, Mansour B, Saeed HM, Hashmi M, Das M, Al Shirawi NN, Mathias R, Ahmed WO, Sharma A, Agarwal D, Nasa P. Knowledge and awareness of infection control practices among nursing professionals: A cross-sectional survey from South Asia and the Middle East. World J Crit Care Med 2023; 12:176-187. [PMID: 37397590 PMCID: PMC10308336 DOI: 10.5492/wjccm.v12.i3.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/15/2023] [Accepted: 05/31/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The proficiency of nursing professionals in the infection prevention and control (IPC) practices is a core component of the strategy to mitigate the challenge of healthcare associated infections.
AIM To test knowledge of nurses working in intensive care units (ICU) in South Asia and Middle East countries on IPC practices.
METHODS An online self-assessment questionnaire based on various aspects of IPC practices was conducted among nurses over three weeks.
RESULTS A total of 1333 nurses from 13 countries completed the survey. The average score was 72.8% and 36% of nurses were proficient (mean score > 80%). 43% and 68.3% of respondents were from government and teaching hospitals, respectively. 79.2% of respondents worked in < 25 bedded ICUs and 46.5% in closed ICUs. Statistically, a significant association was found between the knowledge and expertise of nurses, the country’s per-capita income, type of hospitals, accreditation and teaching status of hospitals and type of ICUs. Working in high- and upper-middle-income countries (β = 4.89, 95%CI: 3.55 to 6.22) was positively associated, and the teaching status of the hospital (β = -4.58, 95%CI: -6.81 to -2.36) was negatively associated with the knowledge score among respondents.
CONCLUSION There is considerable variation in knowledge among nurses working in ICU. Factors like income status of countries, public vs private and teaching status of hospitals and experience are independently associated with nurses’ knowledge of IPC practices.
Collapse
Affiliation(s)
- Kanwalpreet Sodhi
- Department of Critical Care, Deep Hospital, Ludhiana 141001, Punjab, India
| | - Gunjan Chanchalani
- Critical Care Medicine, Somaiya Hospital and Research Centre, Mumbai 400001, Maharashtra, India
| | - Muktanjali Arya
- Department of Microbiology and Infection Control, Deep Hospital, Ludhiana 141001, India
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu 44600, Nepal
| | - Juhi N Chandwani
- Anaesthesia and Intensive Care Unit, Royal Hospital, Muscat 112, Oman
| | - Manender Kumar
- Department of Cardiac Anaesthesia, Fortis Hospital, Ludhiana 141002, Punjab, India
| | - Monika G Kansal
- Intensive Care Medicine, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Mohammad Ashrafuzzaman
- Intensive Care Unit, Bangabandhu Sheikh Mujib Medical University, Dhaka 1000, Bangladesh
| | - Anushka D Mudalige
- Intensive Care Unit, Colombo North Teaching Hospital, Ragama 11010, Sri Lanka
| | - Ashraf Al Tayar
- Intensive Care Unit and Respiratory Therapy Department, Security Forces Hospital, Damman 34223, Saudi Arabia
| | - Bassam Mansour
- Pulmonary and Critical Care Division, Zahraa Hospital-University Medical Center, Beirut 1007, Lebanon
- Pulmonary Division, Faculty of Medical Sciences, Lebanese University, Beirut 1007, Lebanon
| | - Hasan M Saeed
- Department of Critical Care, Salmaniyah Medical Complex, Manama 323, Bahrain
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi 75530, Pakistan
| | - Mitul Das
- Anaesthesia and Critical Care, Swasti Hospital, Rangia 781354, India
| | - Nehad N Al Shirawi
- Department of Critical Care Medicine, Al Fujairah Hospital, Fujairah 0000, United Arab Emirates
| | - Ranjan Mathias
- Department of Anesthesia and Intensive Care, Hamad Medical Corporation, Doha 974, Qatar
| | - Wagih O Ahmed
- Intensive Care Unit, Sulaiman Al Habib Medical Group, Buraidah 52211, Saudi Arabia
| | - Amandeep Sharma
- Department of Nursing, Deep Hospital, Ludhiana 141001, India
| | - Diptimala Agarwal
- Anesthesia and Intensive Care, Shantived Institute of Medical Sciences, Agra 282007, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, Abu Dhabi, United Arab Emirates
| |
Collapse
|
4
|
Sodhi K, Chanchalani G, Arya M, Shrestha GS, Chandwani JN, Kumar M, Kansal MG, Ashrafuzzaman M, Mudalige AD, Al Tayar A, Mansour B, Saeed HM, Hashmi M, Das M, Al Shirawi NN, Mathias R, Ahmed WO, Sharma A, Agarwal D, Nasa P. Knowledge and awareness of infection control practices among nursing professionals: A cross-sectional survey from South Asia and the Middle East. World J Crit Care Med 2023; 12:176-187. [DOI: 10.5492/wjccm.v12.i3.176 sodhi k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
|
5
|
Botta M, Caritg O, van Meenen DMP, Pacheco A, Tsonas AM, Mooij WE, Burgener A, Manrique Hehl T, Shrestha GS, Horn J, Tuinman PR, Paulus F, Roca O, Schultz MJ. Oxygen Consumption with High-Flow Nasal Oxygen versus Mechanical Ventilation- An International Multicenter Observational Study in COVID-19 Patients (PROXY-COVID). Am J Trop Med Hyg 2023; 108:1035-1041. [PMID: 36972693 PMCID: PMC10160903 DOI: 10.4269/ajtmh.22-0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/27/2023] [Indexed: 03/29/2023] Open
Abstract
The COVID-19 pandemic led to local oxygen shortages worldwide. To gain a better understanding of oxygen consumption with different respiratory supportive therapies, we conducted an international multicenter observational study to determine the precise amount of oxygen consumption with high-flow nasal oxygen (HFNO) and with mechanical ventilation. A retrospective observational study was conducted in three intensive care units (ICUs) in the Netherlands and Spain. Patients were classified as HFNO patients or ventilated patients, according to the mode of oxygen supplementation with which a patient started. The primary endpoint was actual oxygen consumption; secondary endpoints were hourly and total oxygen consumption during the first two full calendar days. Of 275 patients, 147 started with HFNO and 128 with mechanical ventilation. Actual oxygen use was 4.9-fold higher in patients who started with HFNO than in patients who started with ventilation (median 14.2 [8.4-18.4] versus 2.9 [1.8-4.1] L/minute; mean difference = 11.3 [95% CI 11.0-11.6] L/minute; P < 0.01). Hourly and total oxygen consumption were 4.8-fold (P < 0.01) and 4.8-fold (P < 0.01) higher. Actual oxygen consumption, hourly oxygen consumption, and total oxygen consumption are substantially higher in patients that start with HFNO compared with patients that start with mechanical ventilation. This information may help hospitals and ICUs predicting oxygen needs during high-demand periods and could guide decisions regarding the source of distribution of medical oxygen.
Collapse
Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Oriol Caritg
- Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - David M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Andrés Pacheco
- Department of Intensive Care, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Willemijn E Mooij
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Alessia Burgener
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Tosca Manrique Hehl
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Amsterdam Neurosciences, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam University Medical Centers, location VUMC, Amsterdam, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Urban Vitality, Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Oriol Roca
- Department of Intensive Care, Parc Taulí de Sabadell University Hospital, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
6
|
Nepal G, Kharel S, Bhagat R, Coghlan MA, Yadav JK, Goeschl S, Lamichhane R, Phuyal S, Ojha R, Shrestha GS. Safety and efficacy of endovascular thrombectomy in patients with severe cerebral venous thrombosis: A meta-analysis. J Cent Nerv Syst Dis 2022; 14:11795735221131736. [PMID: 36204279 PMCID: PMC9530583 DOI: 10.1177/11795735221131736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Abstract
Background Cerebral venous thrombosis (CVT) is a rare thrombotic condition which is traditionally
treated with anti-coagulation therapy. Subsets of patients with severe CVT have been
treated with endovascular thrombectomy (EVT). Despite the high estimated mortality
associated with severe CVT, there has been only one randomized control trial done
regarding safety and efficacy of EVT in severe CVT compared to standard medical
management. Evidence in this area is lacking. Objective The aim of this systematic review is to analyze all existing literature and generate
robust information regarding the role of EVT in the management of patients with severe
CVT. Methods This systematic review and meta-analysis followed PRISMA guideline. PubMed, Embase,
Google Scholar, and CNKI were searched for eligible studies from 2007 to 2021. Safety
and efficacy of EVT were evaluated by meta-analyzing recanalization status, the good
functional outcome at follow-up, recurrent CVT, new hematoma. A pooled proportion with a
95% confidence interval was derived from a meta-analysis of various outcomes (CI). Results A total of 33 studies comprising 610 patients treated with EVT were included for
analysis which comprised one randomized control trial, one prospective study and 31
retrospective studies. Based on pooled data, 85% of patients had good functional
outcome, 62% had complete recanalization, 5% had all-cause mortality, and 3% had
catheter related complications. The efficacy outcomes in this analysis had a significant
heterogeneity and a subgroup analysis was also done to explain these findings. The
minimum time of follow up was 3 months and varied EVT techniques were used across the
studies. Conclusion This meta-analysis suggests EVT may be safe and efficacious in treating patients with
severe CVT. Registration Our protocol was registered with PROSPERO: International prospective register of
systematic reviews with the registration number CRD42021254760.
Collapse
Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Sanjeev Kharel
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Megan A Coghlan
- Department of Neurology, University of Louisville School of
Medicine, Louisville, KY, USA
| | - Jayant K Yadav
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Stella Goeschl
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Rajan Lamichhane
- Department of Internal Medicine,
Maharajgunj Medical Campus, Tribhuvan University Institute of
Medicine, Maharajgunj, Nepal
| | - Subash Phuyal
- Department of Neuroimaging and
Interventional Neuroradiology, Upendra Devkota Memorial National Institute of
Neurological and Allied Sciences, Bansbari, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching
Hospital, Maharajgunj, Nepal,Gentle S Shrestha, Department of Critical Care
Medicine, Tribhuvan University Teaching Hospital, Maharajgunj 44600, Kathmandu, Nepal.
| |
Collapse
|
7
|
Verdonk F, Feyaerts D, Badenes R, Bastarache JA, Bouglé A, Ely W, Gaudilliere B, Howard C, Kotfis K, Lautrette A, Le Dorze M, Mankidy BJ, Matthay MA, Morgan CK, Mazeraud A, Patel BV, Pattnaik R, Reuter J, Schultz MJ, Sharshar T, Shrestha GS, Verdonk C, Ware LB, Pirracchio R, Jabaudon M. Upcoming and urgent challenges in critical care research based on COVID-19 pandemic experience. Anaesth Crit Care Pain Med 2022; 41:101121. [PMID: 35781076 PMCID: PMC9245393 DOI: 10.1016/j.accpm.2022.101121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/03/2022] [Accepted: 06/03/2022] [Indexed: 11/01/2022]
Abstract
While the coronavirus disease 2019 (COVID-19) pandemic placed a heavy burden on healthcare systems worldwide, it also induced urgent mobilisation of research teams to develop treatments preventing or curing the disease and its consequences. It has, therefore, challenged critical care research to rapidly focus on specific fields while forcing critical care physicians to make difficult ethical decisions. This narrative review aims to summarise critical care research -from organisation to research fields- in this pandemic setting and to highlight opportunities to improve research efficiency in the future, based on what is learned from COVID-19. This pressure on research revealed, i.e., i/ the need to harmonise regulatory processes between countries, allowing simplified organisation of international research networks to improve their efficiency in answering large-scale questions; ii/ the importance of developing translational research from which therapeutic innovations can emerge; iii/ the need for improved triage and predictive scores to rationalise admission to the intensive care unit. In this context, key areas for future critical care research and better pandemic preparedness are artificial intelligence applied to healthcare, characterisation of long-term symptoms, and ethical considerations. Such collaborative research efforts should involve groups from both high and low-to-middle income countries to propose worldwide solutions. As a conclusion, stress tests on healthcare organisations should be viewed as opportunities to design new research frameworks and strategies. Worldwide availability of research networks ready to operate is essential to be prepared for next pandemics. Importantly, researchers and physicians should prioritise realistic and ethical goals for both clinical care and research.
Collapse
Affiliation(s)
- Franck Verdonk
- Department of Anaesthesiology and Intensive Care, Hôpital Saint-Antoine Paris, Assistance Publique-Hôpitaux de Paris, France and GRC 29, DMU DREAM, Sorbonne University, Paris, France; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, California, United States of America
| | - Dorien Feyaerts
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, California, United States of America
| | - Rafael Badenes
- Department of Anaesthesiology and Intensive Care, Hospital Clìnico Universitario de Valencia, University of Valencia, Valencia, Spain
| | - Julie A Bastarache
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Adrien Bouglé
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, Institute of Cardiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, at the TN Valley VA Geriatric Research Education Clinical Center (GRECC) and Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, California, United States of America
| | - Christopher Howard
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Katarzyna Kotfis
- Department Anaesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel-Montpied University Hospital, Clermont-Ferrand, France
| | - Matthieu Le Dorze
- Department of Anaesthesiology and Critical Care Medicine, AP-HP, Lariboisière University Hospital, Paris, France
| | - Babith Joseph Mankidy
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Michael A Matthay
- Departments of Medicine and Anaesthesia, University of California, and Cardiovascular Research Institute, San Francisco, California, United States of America
| | - Christopher K Morgan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Aurélien Mazeraud
- Service d'Anesthésie-Réanimation, Groupe Hospitalier Université Paris Psychiatrie et Neurosciences, Pôle Neuro, Paris, France
| | - Brijesh V Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College, and Department of Adult Intensive Care, Royal Brompton & Harefield Hospitals, Guys & St Thomas' NHS Foundation trust, London, UK
| | - Rajyabardhan Pattnaik
- Department of Intensive Care Medicine, Ispat General Hospital, Rourkela, Sundargarh, Odisha, India
| | - Jean Reuter
- Department of Intensive Care Medicine, Centre Hospitalier de Luxembourg, Luxembourg
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC, location AMC, Amsterdam, The Netherlands
| | - Tarek Sharshar
- Service d'Anesthésie-Réanimation, Groupe Hospitalier Université Paris Psychiatrie et Neurosciences, Pôle Neuro, Paris, France
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Charles Verdonk
- Unit of Neurophysiology of Stress, Department of Neurosciences and Cognitive Sciences, French Armed Forces Biomedical Research Institute, Brétigny-sur-Orge, France
| | - Lorraine B Ware
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, California, United States of America
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; iGReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France.
| |
Collapse
|
8
|
Chanchalani G, Arora N, Nasa P, Sodhi K, Bahrani MJA, Tayar AA, Hashmi M, Jaiswal V, Kantor S, Lopa AJ, Mansour B, Mudalige AD, Nadeem R, Shrestha GS, Taha AR, Türkoğlu M, Weeratunga D. Visiting and Communication Policy in Intensive Care Units during COVID-19 Pandemic: A Cross-sectional Survey from South Asia and the Middle East. Indian J Crit Care Med 2022; 26:268-275. [PMID: 35519910 PMCID: PMC9015923 DOI: 10.5005/jp-journals-10071-24091] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The coronavirus disease-2019 (COVID-19) pandemic had affected the visiting or communicating policies for family members. We surveyed the intensive care units (ICUs) in South Asia and the Middle East to assess the impact of the COVID-19 pandemic on visiting and communication policies. MATERIALS AND METHOD A web-based cross-sectional survey was used to collect data between March 22, 2021, and April 7, 2021, from healthcare professionals (HCP) working in COVID and non-COVID ICUs (one response per ICU). The topics of the questionnaire included current and pre-pandemic policies on visiting, communication, informed consent, and end-of-life care in ICUs. RESULTS A total of 292 ICUs (73% of COVID ICUs) from 18 countries were included in the final analysis. Most (92%) of ICUs restricted their visiting hours, and nearly one-third (32.3%) followed a "no-visitor" policy. There was a significant change in the daily visiting duration in COVID ICUs compared to the pre-pandemic times (p = 0.011). There was also a significant change (p <0.001) in the process of informed consent and end-of-life discussions during the ongoing pandemic compared to pre-pandemic times. CONCLUSION Visiting and communication policies of the ICUs had significantly changed during the COVID-19 pandemic. Future studies are needed to understand the sociopsychological and medicolegal implications of revised policies. HOW TO CITE THIS ARTICLE Chanchalani G, Arora N, Nasa P, Sodhi K, Al Bahrani MJ, Al Tayar A, et al. Visiting and Communication Policy in Intensive Care Units during COVID-19 Pandemic: A Cross-sectional Survey from South Asia and the Middle East. Indian J Crit Care Med 2022;26(3):268-275.
Collapse
Affiliation(s)
- Gunjan Chanchalani
- Department of Critical Care Medicine, Cumballa Hill Hospital, Mumbai, Maharashtra, India
| | - Nitin Arora
- Department of Intensive Care, University Hospitals Birmingham, Birmingham, West Midlands, United Kingdom
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
- Prashant Nasa, Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates, Phone: +971501425022, e-mail:
| | | | - Maher J Al Bahrani
- Department of Anesthesiology and Critical Care Medicine, Royal Hospital, Muscat, Oman
| | - Ashraf Al Tayar
- Department of ICU, Security Force Hospital, Dammam, Saudi Arabia
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University and Dr Ziauddin Hospital, Karachi, Pakistan
| | - Vinod Jaiswal
- Department of Critical Care Medicine, Amina Hospital, Ajman, United Arab Emirates
| | - Sandeep Kantor
- Department of Critical Care Medicine, Royal Hospital, Muscat, Oman
| | - Ahsina J Lopa
- Department of Intensive Care Unit, MH Samorita Hospital and Medical College, Tejgaon, Dhaka, Bangladesh
| | - Bassam Mansour
- Department of Pulmonary Medicine and Critical Care Medicine, Zahraa Hospital University Medical Center/Lebanese University, Faculty of Medical Science, Beirut, Lebanon
| | - Anushka D Mudalige
- Department of Critical Care Medicine, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - Rashid Nadeem
- Department of Critical Care Medicine, Dubai Hospital, Dubai, United Arab Emirates
| | - Gentle S Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Lalitpur, Nepal
| | - Ahmed R Taha
- Department of Critical Care Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Melda Türkoğlu
- Department of Internal Medicine, Division of Critical Care, Gazi University, Faculty of Medicine, Ankara, Turkey
| | - Dameera Weeratunga
- Department of Critical Care Medicine, National Hospital of Sri Lanka, Colombo, Sri Lanka
| |
Collapse
|
9
|
Prust M, Saylor D, Zimba S, Sarfo FS, Shrestha GS, Berkowitz A, Vora N. Inpatient Management of Acute Stroke of Unknown Type in Resource-Limited Settings. Stroke 2022; 53:e108-e117. [PMID: 35045720 PMCID: PMC8885836 DOI: 10.1161/strokeaha.121.037297] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is the second leading cause of death and disability worldwide, with a disproportionate burden on low- and middle-income countries. Critical elements of guideline-based stroke care developed in high-income countries are not applicable to resource-limited settings, where lack of access to neuroimaging prevents clinicians from distinguishing between ischemic stroke and intracranial hemorrhage, requiring challenging clinical decision-making, particularly in the acute setting. We discuss strategies for acute inpatient management of stroke of unknown type with a focus on blood pressure management and antiplatelet therapy when neuroimaging is unavailable, and review some of the challenges and strategies for successfully implementing stroke unit care in resource-limited health care settings.
Collapse
Affiliation(s)
| | - Deanna Saylor
- Johns Hopkins University Hospital, Baltimore, MD, USA,University Teaching Hospital, Lusaka, Zambia
| | | | | | | | - Aaron Berkowitz
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Nirali Vora
- Stanford University Medical Center, Stanford, CA, USA
| |
Collapse
|
10
|
Nepal G, Shrestha GS, Shing YK, Yadav JK, Coghlan MA, Ojha R. Low‐cost alternatives for the management of Guillain‐Barré syndrome in low‐ and middle‐income countries. World Med & Health Policy 2021. [DOI: 10.1002/wmh3.474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Gentle S. Shrestha
- Department of Anesthesiology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| | - Yow K. Shing
- Department of Internal Medicine National University Hospital Singapore Singapore
| | - Jayant K. Yadav
- Department of Internal Medicine, Maharajgunj Medical Campus Tribhuvan University Institute of Medicine Maharajgunj Kathmandu Nepal
| | - Megan A. Coghlan
- Department of Neurology University of Louisville School of Medicine Louisville Kentucky USA
| | - Rajeev Ojha
- Department of Neurology Tribhuvan University Teaching Hospital Maharajgunj Kathmandu Nepal
| |
Collapse
|
11
|
Schultz MJ, Roca O, Shrestha GS. Global lessons learned from COVID-19 mass casualty incidents. Br J Anaesth 2021; 128:e97-e100. [PMID: 34865825 PMCID: PMC8590954 DOI: 10.1016/j.bja.2021.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 12/15/2022] Open
Abstract
With healthcare systems rapidly becoming overwhelmed and occupied by patients during a pandemic, effective and safe care for patients is easily compromised. During the course of the current pandemic, numerous treatment guidelines have been developed and published that have improved care for patients with COVID-19. Certain lessons have only been learned during the course of the outbreak, from which we can learn for future pandemics. This editorial aims to raise awareness about the importance of timely stockpiling of sufficient amounts of personal protection equipment and medications, adequate oxygen supplies, uninterrupted electricity, and fair locally adapted triage strategies.
Collapse
Affiliation(s)
- Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands; Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Vall d'Hebron, Barcelona, Spain; Ciber Enfermedades Respiratorias (CibeRes), Instituto de Salud Carlos III, Madrid, Spain
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| |
Collapse
|
12
|
Shrestha GS, Keyal N. Basilar Artery Aneurysm Presenting as a Stroke Mimic. Neurol India 2021; 69:1434-1435. [PMID: 34747835 DOI: 10.4103/0028-3886.329592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Gentle S Shrestha
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Niraj Keyal
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| |
Collapse
|
13
|
Affiliation(s)
- Pankaj Jalan
- Department of Neurology, Norvic International Hospital, Thapathali, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
14
|
Schultz MJ, Tun NN, Shrestha GS. Caring for Hospitalized COVID-19 Patients: From Hypes and Hopes to Doing the Simple Things First. Am J Trop Med Hyg 2021; 106:751-753. [PMID: 34724635 PMCID: PMC8922481 DOI: 10.4269/ajtmh.21-0961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Amsterdam University Medical Centers, AMC, Amsterdam, The Netherlands.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ni Ni Tun
- Myanmar-Oxford Clinical Research Unit (MOCRU), Yangon, Myanmar.,Medical Action Myanmar (MAM), Yangon, Myanmar
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| |
Collapse
|
15
|
Lumb PD, Adler DC, Al Rahma H, Amin P, Bakker J, Bhagwanjee S, Du B, Bryan-Brown CW, Dobb G, Gingles B, Jacobi J, Koh Y, Razek AA, Peden C, Shrestha GS, Shukri K, Singer M, Taylor P, Williams G. International Critical Care-From an Indulgence of the Best-Funded Healthcare Systems to a Core Need for the Provision of Equitable Care. Crit Care Med 2021; 49:1589-1605. [PMID: 34259443 DOI: 10.1097/ccm.0000000000005188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip D Lumb
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Bombay, India
| | | | | | - Bin Du
- Peking Union Medical College, Beijing, China
| | | | - Geoffrey Dobb
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | | | | | - Younsuck Koh
- University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Carol Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Khalid Shukri
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | | | - Phil Taylor
- World Federation of Intensive and Critical Care (WFICC)
| | | |
Collapse
|
16
|
Abstract
It is difficult to predict the future course and length of the ongoing COVID-19 pandemic, which has devastated health care systems in low- and middle-income countries. Anesthesiology and critical care services are hard hit because many hospitals have stopped performing elective surgeries, staff and scarce hospital resources have been diverted to manage COVID-19 patients, and several makeshift COVID-19 units had to be set up. Intensive care units are overwhelmed with critically ill patients. In these difficult times, low- and middle-income countries need to improvise, perform indigenous research, adapt international guidelines to suit local needs, and target attainable clinical goals.
Collapse
Affiliation(s)
- Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj Road, PO Box: 1524, Maharajgunj, Kathmandu 44600, Nepal.
| | - Ritesh Lamsal
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj Road, PO Box: 1524, Maharajgunj, Kathmandu 44600, Nepal
| | - Pradip Tiwari
- Department of Critical Care, Norvic International Hospital, PO Box: 14126, Thapathali, Kathmandu 44617, Nepal
| | - Subhash P Acharya
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj Road, PO Box: 1524, Maharajgunj, Kathmandu 44600, Nepal
| |
Collapse
|
17
|
Poudyal BS, Shrestha GS. Giant hemophilic pseudotumor eroding the iliac bone. Oxf Med Case Reports 2021; 2021:omab005. [PMID: 33732484 PMCID: PMC7947266 DOI: 10.1093/omcr/omab005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/06/2021] [Indexed: 11/27/2022] Open
Affiliation(s)
- Bishesh S Poudyal
- Clinical Haematology and Bone Marrow Transplant Unit, Government of Nepal, Civil Service Hospital, Minbhawan, New Baneshwor, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
18
|
West TE, Schultz MJ, Ahmed HY, Shrestha GS, Papali A. Pragmatic Recommendations for Tracheostomy, Discharge, and Rehabilitation Measures in Hospitalized Patients Recovering From Severe COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:110-119. [PMID: 33534772 PMCID: PMC7957235 DOI: 10.4269/ajtmh.20-1173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 01/04/2021] [Indexed: 12/14/2022] Open
Abstract
New studies of COVID-19 are constantly updating best practices in clinical care. However, research mainly originates in resource-rich settings in high-income countries. Often, it is impractical to apply recommendations based on these investigations to resource-constrained settings in low- and middle-income countries (LMICs). We report on a set of pragmatic recommendations for tracheostomy, discharge, and rehabilitation measures in hospitalized patients recovering from severe COVID-19 in LMICs. We recommend that tracheostomy be performed in a negative pressure room or negative pressure operating room, if possible, and otherwise in a single room with a closed door. We recommend using the technique that is most familiar to the institution and that can be conducted most safely. We recommend using fit-tested enhanced personal protection equipment, with the fewest people required, and incorporating strategies to minimize aerosolization of the virus. For recovering patients, we suggest following local, regional, or national hospital discharge guidelines. If these are lacking, we suggest deisolation and hospital discharge using symptom-based criteria, rather than with testing. We likewise suggest taking into consideration the capability of primary caregivers to provide the necessary care to meet the psychological, physical, and neurocognitive needs of the patient.
Collapse
Affiliation(s)
- T. Eoin West
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Marcus J. Schultz
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Hanan Y. Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S. Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - for the COVID-LMIC Task Force and the Mahidol-Oxford Research Unit (MORU)
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers, Location ‘AMC’, Amsterdam, The Netherlands
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| |
Collapse
|
19
|
Ahmed HY, Papali A, Haile T, Shrestha GS, Schultz MJ, Lundeg G, Akrami KM, For The Covid-Lmic Task Force. Pragmatic Recommendations for the Management of Anticoagulation and Venous Thrombotic Disease for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries. Am J Trop Med Hyg 2021; 104:99-109. [PMID: 33432908 PMCID: PMC7957232 DOI: 10.4269/ajtmh.20-1305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/23/2020] [Indexed: 12/19/2022] Open
Abstract
New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.
Collapse
Affiliation(s)
- Hanan Y Ahmed
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alfred Papali
- Division of Pulmonary and Critical Care Medicine, Atrium Health, Charlotte, North Carolina
| | - Tewodros Haile
- Division of Pulmonary and Critical Care Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Amsterdam University Medical Centers, Location 'Academic Medical Center', Amsterdam, The Netherlands
| | - Ganbold Lundeg
- Critical Care and Anaesthesia Department, Mongolian National University of Medical Sciences, Ulan Bator, Mongolia
| | - Kevan M Akrami
- Divisions of Infectious Disease and Critical Care Medicine, University of California San Diego, San Diego, California.,Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil
| | | |
Collapse
|
20
|
Hamal PK, Chaurasia RB, Pokhrel N, Pandey D, Shrestha GS. An affordable videolaryngoscope for use during the COVID-19 pandemic. Lancet Glob Health 2020; 8:e893-e894. [PMID: 32562645 PMCID: PMC7837320 DOI: 10.1016/s2214-109x(20)30259-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Pawan Kumar Hamal
- Department of Anaesthesiology and Intensive Care, National Academy of Medical Sciences, National Trauma Center, Kathmandu, Nepal
| | - Roshan Bhagat Chaurasia
- Department of Orthopaedics, National Academy of Medical Sciences, National Trauma Center, Kathmandu, Nepal
| | - Nabin Pokhrel
- Department of Anaesthesiology and Intensive Care, National Academy of Medical Sciences, National Trauma Center, Kathmandu, Nepal
| | - Dipendra Pandey
- Department of Orthopaedics, National Academy of Medical Sciences, National Trauma Center, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
| |
Collapse
|
21
|
Pradhan RR, Shrestha GS, Sedain G. Remote Supratentorial Subdural Hematoma Following Craniectomy and Evacuation of Hypertensive Cerebellar Hematoma. Cureus 2020; 12:e6977. [PMID: 32201656 PMCID: PMC7075514 DOI: 10.7759/cureus.6977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Remote acute subdural hematoma following a decompressive craniotomy or craniectomy is a rare phenomenon. Only few cases of postoperative contralateral acute subdural hematomas have been reported in the literature review till date. This case report details a case of a 32-year-old hypertensive male who presented with severe headache, multiple episodes of vomiting, slurring of speech, nystagmus and ataxic gait for one day. Computed tomography (CT) scan of head revealed a right sided cerebellar hemorrhage with effacement of fourth ventricle and upstream hydrocephalus. A right suboccipital craniectomy and hematoma evacuation were performed. A repeat CT scan of head was done at six hours post surgery; which revealed a contralateral (left-sided) subdural hematoma involving the fronto-parieto-temporal region. The patient improved following conservative management. Contralateral acute subdural hematoma following evacuation of hematoma is a rare, but a potentially life-threatening complication; therefore, we should try to detect such contralateral hematoma and prevent clinical deterioration.
Collapse
Affiliation(s)
- Ravi R Pradhan
- Internal Medicine, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| | - Gentle S Shrestha
- Critical Care, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, NPL
| | - Gopal Sedain
- Neurosurgery, Tribhuvan University Institute of Medicine, Kathmandu, NPL
| |
Collapse
|
22
|
Abstract
Introduction At present, there is an emphasis on a multi-modal approach to neuro-prognostication after cardiac arrest using clinical examination, neurophysiologic testing, laboratory biomarkers, and radiological studies. However, this necessitates significant resource utilization and can be challenging in under-resourced clinical settings. Hence, we sought to determine the inter-predictability and correlation of prognostic tests performed in patients after cardiac arrest. Methods Fifty patients were included through neurophysiology laboratory data for this retrospective study. Clinical, radiological and neurophysiological data were collected. Neurophysiological data were re-evaluated by a board-certified neurophysiologist for the purpose of the study. Chi-square testing was used to evaluate the correlation between different diagnostic modalities. Results We found that a non-reactive electroencephalogram (EEG) had a predictive value of 79% for absent bilateral cortical responses (N20) with somatosensory evoked potentials (SSEP). On the other hand, absent bilateral cortical responses N20 had 87% predictive value for a non-reactive EEG. Also, absent cortical responses and non-reactive EEG had predictive values of 78% and 72% for anoxic injury on magnetic resonance imaging (MRI) brain respectively with a non-significant difference on chi-square testing. Individually, absent bilateral N20 SSEP, a non-reactive EEG and anoxic brain injury on MRI studies were highly predictive of poor outcome [modified Rankin scale (mRS) > 4] at hospital discharge. Conclusion Neuroprognostication in a post-cardiac arrest setting is often limited by self-fulfilling prophecy. Given the lack of absolute correlation between different modalities used in post-cardiac arrest patients, the value of the multi-modal approach to neuro-prognostication is highlighted by this study.
Collapse
Affiliation(s)
- Tapan Kavi
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Masoom Desai
- Neurology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Furkan M Yilmaz
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | - Bhavika Kakadia
- Neurology, Cooper Neurological Institute, Cooper University Hospital, Camden, USA
| | | | - Gentle S Shrestha
- Critical Care, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, NPL
| |
Collapse
|
23
|
Shrestha GS, Weeratunga D, Baker K. Point-of-Care Lung Ultrasound in Critically ill Patients. Rev Recent Clin Trials 2019; 13:15-26. [PMID: 28901850 DOI: 10.2174/1574887112666170911125750] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 08/13/2017] [Accepted: 08/16/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Lung ultrasound is increasingly being used by the bedside physicians to complement the findings of physical examination. Lung ultrasound is non-invasive, devoid of radiation exposure and can be performed rapidly and repeatedly as needed at bedside. This review aims to elucidate the evidence base and the future directions for bedside point-of-care lung ultrasound in critically ill patients. METHODS Research articles, review papers and online contents related to point-of-care ultrasound in critically ill patients were reviewed. RESULTS The diagnostic accuracy of lung ultrasound for common conditions like pleural effusion, pneumothorax, pulmonary edema and pneumonia is superior to chest radiograph and is comparable to chest CT scan. Lung ultrasound is helpful to evaluate the progress of lung pathology and response to treatment, over time. Ultrasound guidance for thoracocentesis decreases the complication rates. CONCLUSION Bedside lung ultrasound in critically ill patients can serve as a tool to diagnose common lung pathologies, monitor its course and guide clinical management.
Collapse
Affiliation(s)
- Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | | | - Kylie Baker
- University of Queensland, St. Lucia QLD 4072, Australia
| |
Collapse
|
24
|
Shrestha GS, Kwizera A, Lundeg G, Baelani JI, Azevedo LCP, Pattnaik R, Haniffa R, Gavrilovic S, Mai NTH, Kissoon N, Lodha R, Misango D, Neto AS, Schultz MJ, Dondorp AM, Thevanayagam J, Dünser MW, Alam AKMS, Mukhtar AM, Hashmi M, Ranjit S, Otu A, Gomersall C, Amito J, Vaeza NN, Nakibuuka J, Mujyarugamba P, Estenssoro E, Ospina-Tascón GA, Mohanty S, Mer M. International Surviving Sepsis Campaign guidelines 2016: the perspective from low-income and middle-income countries. Lancet Infect Dis 2018; 17:893-895. [PMID: 28845789 DOI: 10.1016/s1473-3099(17)30453-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 06/30/2017] [Accepted: 07/26/2017] [Indexed: 01/26/2023]
Affiliation(s)
- Gentle S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu 44600, Nepal.
| | - Arthur Kwizera
- Department of Anaesthesia, Anaesthesia and General Intensive Care, Mulago National Referral Hospital, Makerere University, Kampala, Uganda
| | - Ganbold Lundeg
- Department of Critical Care and Anesthesia, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - John I Baelani
- Department of Anesthesia and Emergency, Doctors on Call for Service Education Hospital, Goma, Democratic Republic of the Congo
| | - Luciano C P Azevedo
- Emergency Department, University of São Paulo, São Paulo, Brazil; Hospital Sírio-Libanes, São Paulo, Brazil
| | | | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Srdjan Gavrilovic
- Institute for Pulmonary Diseases of Vojvodina, The Clinic for Urgent Pulmonology, Sremska Kamenica, Serbia; Department of Emergency Medicine, Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Nguyen Thi Hoang Mai
- Hospital For Tropical Diseases, Oxford University Clinical Research Unit Vietnam, Ho Chi Minh City, Vietnam
| | - Niranjan Kissoon
- Department of Paediatrics and Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - David Misango
- Department of Critical Care Medicine, Aga Khan University Hospital, Nairobi, Kenya
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcus J Schultz
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam Medical Center and University of Amsterdam, Amsterdam, Netherlands
| | - Arjen M Dondorp
- Mahidol-Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Department of Intensive Care, Amsterdam Medical Center and University of Amsterdam, Amsterdam, Netherlands
| | | | - Martin W Dünser
- Department of Critical Care Medicine, University College of London Hospitals, London, UK
| | - A K M Shamsul Alam
- Department of Anaesthesia and Intensive Care, Chittagong Medical College, Chittagong, Bangladesh
| | - Ahmed M Mukhtar
- Department of Anesthesia and Intensive Care, Cairo University, Cairo, Egypt
| | - Madiha Hashmi
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Suchitra Ranjit
- Pediatric Intensive Care and Emergency Services, Apollo Children's Hospital, Chennai, Tamil Nadu, India
| | - Akaninyene Otu
- Department of Internal Medicine, University of Calabar, Calabar, Nigeria
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jacinta Amito
- Department of Anaesthetics and Intensive Care, St Mary's Hospital Lacor, Gulu, Uganda
| | | | - Jane Nakibuuka
- Department of Medicine, General Intensive Care Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Pierre Mujyarugamba
- Medical Laboratory Technology Department, University of Gitwe, Gitwe, Rwanda
| | - Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal de Agudos San Martín de La Plata, Buenos Aires, Argentina
| | - Gustavo A Ospina-Tascón
- Department of Intensive Care Medicine, Fundación Valle del Lili - Universidad ICESI, Cali, Colombia
| | | | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
25
|
McCredie VA, Shrestha GS, Acharya S, Bellini A, Singh JM, Hemphill JC, Goffi A. Evaluating the effectiveness of the Emergency Neurological Life Support educational framework in low-income countries. Int Health 2018; 10:116-124. [PMID: 29506188 PMCID: PMC5856183 DOI: 10.1093/inthealth/ihy003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 12/22/2017] [Accepted: 02/09/2018] [Indexed: 11/13/2022] Open
Abstract
Background The Emergency Neurological Life Support (ENLS) is an educational initiative designed to improve the acute management of neurological injuries. However, the applicability of the course in low-income countries in unknown. We evaluated the impact of the course on knowledge, decision-making skills and preparedness to manage neurological emergencies in a resource-limited country. Methods A prospective cohort study design was implemented for the first ENLS course held in Asia. Knowledge and decision-making skills for neurological emergencies were assessed at baseline, post-course and at 6 months following course completion. To determine perceived knowledge and preparedness, data were collected using surveys administered immediately post-course and 6 months later. Results A total of 34 acute care physicians from across Nepal attended the course. Knowledge and decision-making skills significantly improved following the course (p=0.0008). Knowledge and decision-making skills remained significantly improved after 6 months, compared with before the course (p=0.02), with no significant loss of skills immediately following the course to the 6-month follow-up (p=0.16). At 6 months, the willingness to participate in continuing medical education activities remained evident, with 77% (10/13) of participants reporting a change in their clinical practice and decision-making, with the repeated use of ENLS protocols as the main driver of change. Conclusions Using the ENLS framework, neurocritical care education can be delivered in low-income countries to improve knowledge uptake, with evidence of knowledge retention up to 6 months.
Collapse
Affiliation(s)
- Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Gentle S Shrestha
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Subhash Acharya
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Antonio Bellini
- Department of Anesthesia, Queen’s Hospital, Barking Havering and Redbridge University Hospital NHS Trust, London, UK
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - J Claude Hemphill
- Department of Neurology, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, ON, Canada
| |
Collapse
|
26
|
Mehta S, Burns KEA, Machado FR, Fox-Robichaud AE, Cook DJ, Calfee CS, Ware LB, Burnham EL, Kissoon N, Marshall JC, Mancebo J, Finfer S, Hartog C, Reinhart K, Maitland K, Stapleton RD, Kwizera A, Amin P, Abroug F, Smith O, Laake JH, Shrestha GS, Herridge MS. Gender Parity in Critical Care Medicine. Am J Respir Crit Care Med 2017; 196:425-429. [PMID: 28240961 DOI: 10.1164/rccm.201701-0076cp] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. These documents inform and shape patient care around the world. In this Perspective we discuss the importance of diversity on guideline panels, the disproportionately low representation of women on critical care guideline panels, and existing initiatives to increase the representation of women in corporations, universities, and government. We propose five strategies to ensure gender parity within critical care medicine.
Collapse
Affiliation(s)
- Sangeeta Mehta
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,3 Sinai Health System
| | - Karen E A Burns
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Flavia R Machado
- 7 Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Alison E Fox-Robichaud
- 4 Canadian Critical Care Society, Markham, Ontario, Canada.,8 Hamilton Health Sciences, Thrombosis and Atherosclerosis Research Institute.,9 Department of Medicine
| | - Deborah J Cook
- 10 Clinical Epidemiology and Biostatistics, and.,11 Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn S Calfee
- 12 Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine and.,13 Cardiovascular Research Institute, University of California, San Francisco, California
| | - Lorraine B Ware
- 14 Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ellen L Burnham
- 15 Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Niranjan Kissoon
- 16 Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - John C Marshall
- 5 Interdepartmental Division of Critical Care Medicine and.,17 Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jordi Mancebo
- 18 University of Montreal Hospital Center and.,19 Division of Intensive Care, University of Montreal, Montreal, Quebec, Canada
| | - Simon Finfer
- 20 Division of Critical Care and Trauma, The George Institute for Global Health, Sydney, Australia.,21 University of Sydney, Sydney, Australia
| | - Christiane Hartog
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- 22 Department of Anesthesiology and Intensive Care, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,23 Global Sepsis Alliance, Jena, Germany
| | - Kathryn Maitland
- 24 Wellcome Trust Centre for Clinical Tropical Medicine, Department of Paediatrics, Imperial College London, London, United Kingdom
| | - Renee D Stapleton
- 25 Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington, Vermont
| | - Arthur Kwizera
- 26 Department of Anesthesia and Critical Care, Makerere University, Kampala, Uganda
| | - Pravin Amin
- 27 Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Fekri Abroug
- 28 Centre Hospitalo-Universitaire Fattouma Bourguiba, Monastir, Tunisia
| | - Orla Smith
- 29 Lawrence S. Bloomberg Faculty of Nursing, and.,5 Interdepartmental Division of Critical Care Medicine and.,6 Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Jon H Laake
- 30 Scandinavian Society of Anaesthesiology and Intensive Care Medicine.,31 Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; and
| | - Gentle S Shrestha
- 32 Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Margaret S Herridge
- 1 Department of Medicine.,2 Interdepartmental Division of Critical Care Medicine.,33 University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
27
|
Shrestha RK, Shrestha GS. Ocular Morbidity among Children of Government Schools of Kathmandu Valley: A Follow-up Study. JNMA J Nepal Med Assoc 2017; 56:243-247. [PMID: 28746323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
INTRODUCTION Ocular and vision defects are common among school going children. Vision disorders, especially refractive errors are the main disabilities of children and the leading cause of handicapping conditions of childhood. The present study was conducted to find out ocular morbidity among students of government schools of Kathmandu valley. METHODS In the descriptive and cross-sectional study, 2412 students, comprising of 1114 (46.2%) males and 1298 (53.8%) females were enrolled in to the study from the five government schools of Kathmandu valley from 2012 to 2013. Detailed eye examination included distance visual acuity testing, anterior and posterior segment examinations, retinoscopy and refraction, cover test, near point of convergence, amplitude of accommodation and color vision test. The Chi-square test was performed to analyze the association between ocular morbidity, age and sex. P value was considered significant at 0.05 for 95% confidence interval. RESULTS Majority of children were age group between 11 and 13 years (n= 783, 32.5%). A male to female ratio was 0.85. Presenting and best spectacle corrected visual acuity of 6/6 was present in 2257 (93.6%) and 2380 (98.7%) respectively. Total ocular morbidity was observed in 515 (21.4%) subjects. The most common types of ocular morbidity were refractive error in 241 (10%), conjunctivitis in 104 (4.3%) and convergence insufficiency in 82 (3.4%). CONCLUSIONS Refractive error, conjunctivitis and convergence insufficiency represent the most common ocular morbidities among students of government schools.
Collapse
Affiliation(s)
- R K Shrestha
- Department of Ophthalmology, Nepal Medical College, Jorpati, Kathmandu, Nepal
| | - G S Shrestha
- Department of Ophthalmology, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
28
|
Abstract
Point-of-care ultrasonography has been used frequently by the physicians involved in managing critically ill patients. It allows direct visualization of pathology or abnormal physiological state at the bed side. The examination may be safely and effectively repeated as needed to follow the evolution of illness and the response to therapy. It is helpful to guide the therapy in patients with undifferentiated shock and for bedside diagnosis of common pathological conditions in acute care setting. It can facilitate common bedside procedures and interventions.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology Institute of Medicine, TUTH Kathmandu, Nepal
| |
Collapse
|
29
|
Affiliation(s)
- Gentle S Shrestha
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
30
|
Poudyal BS, Sapkota B, Shrestha GS, Thapalia S, Gyawali B, Tuladhar S. Safety and Efficacy of Azathioprine as a Second Line Therapy for Primary Immune Thrombocytopenic Purpura. JNMA J Nepal Med Assoc 2016; 55:16-21. [PMID: 27935917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION Immune thrombocytopenic purpura remains common blood disease in Nepal. Azathioprine is an oral immunosupressive medicine which has been used widely in various autoimmune disease and solid organ transplant patients. It is inexpensive, easily available and well tolerated medicine. This study was carried out to evaluate efficacy and safety of azathioprine as a second line medicine for primary ITP patients who were refractory to steroid therapy. METHODS The observational, pre-post study was conducted at Government of Nepal Civil Service Hospital, Kathmandu from January to October 2014. Twenty four primary ITP patients who were steroid refractory were treated with Azathioprine. Patients were termed steroid refractory if platelet counts were less than 30,000/ul on day 21st of steroid therapy. From day 22 onwards oral azathioprine 2mg/kg was started and steroids were tapered 10mg/week and stopped. Platelet counts of more than 30000/ul after one month of stopping steroid, while still on azathioprine, were termed response to azathioprine. Platelet count of more than 100,000/ul was termed complete response. The associations among age, gender, duration and platelets counts were analyzed by chi square test and Fisher's exact test (when individual cell frequency was less than 5). The comparison of platelets counts among the start and day 90 of Azathioprine therapy was performed by the paired t-test. RESULTS The study showed that there was not significant association among age and gender of the patients and their platelets count on the start of Azathioprine therapy (p value 0.354 and 0.725 respectively) and on day 90 of Azathioprine therapy (p value 0.082 and 0.762 respectively). The duration-wise comparisons of platelets count on both the start and day 90 of Azathioprine therapy were significant (p values 0.029 and 0.008 respectively). The paired comparison among platelets count on the start and day 90 of Azathioprine therapy was highly significant (p value 0.000). CONCLUSIONS The study showed the therapeutic implication of azathioprine in ITP patients. It also showed that efficacy of azathioprine was comparable with other modes of treatment. In low income countries like Nepal azathioprine can be considered as second line treatment for steroid refractory ITP patients.
Collapse
Affiliation(s)
- B S Poudyal
- Clinical Hematology and Bone Marrow Transplant Unit, Government of Nepal Civil Service Hospital, Kathmandu, Nepal
| | - B Sapkota
- Department of Pharmacology, Civil Service Hospital, Kathmandu, Nepal
| | - G S Shrestha
- Intensive Care Unit, Tribhuwan University Teaching Hospital, Kathmandu, Nepal
| | - S Thapalia
- Mid Western Regional Hospital, Surkhet, Nepal
| | - B Gyawali
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan
| | - S Tuladhar
- Department of Pathology and Clinical Hematology, Civil Service Hospital, Kathmandu, Nepal
| |
Collapse
|
31
|
Shrestha S, Shrestha GS, Sharma A. Immediate Outcome of Hypoxic Ischaemic Encephalopathy in Hypoxiate Newborns in Nepal Medical College. J Nepal Health Res Counc 2016; 14:77-80. [PMID: 27885286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Birth asphyxia is the fifth major cause of under-five child deaths after pneumonia, diarrhoea, neonatal infections and complications of preterm birth. It is one of the important causes of neonatal mortality and morbidity accounting up to 30% of neonatal death in Nepal. It is also an important cause of long-term neurological disability and impairment. The mortality rate due to birth asphyxia is considered a good guide to the quality of perinatal care. This study was conducted to assess the rate of birth asphyxia, risk factors and outcome of the babies who were asphyxiated at birth. METHODS A prospective study was conducted during the period of one year from April 2013 to March 2014 in Nepal Medical College. All the term babies born during the period with APGAR score at 5 minutes of < 7 were considered to have birth asphyxia and included in the study. Details of maternal risk factors during pregnancy and labor were analyzed. The newborn babies were assessed for clinical features of hypoxic ischemic encephalopathy (HIE) and its immediate outcome. RESULTS Out of 2226 live births, 47 (15.9%) newborns had birth asphyxia with the rate of 21.1/1000 live births. The mortality rate due to birth asphyxia was 4.25%. Meconium stained liquor was present in 31(65.96%) cases during delivery and prolonged rupture of membrane in 7(14.89%). CONCLUSIONS Early identification and close monitoring of high-risk mothers with maintaining partograph during labor help to reduce birth asphyxia.
Collapse
Affiliation(s)
- S Shrestha
- Department of Paediatrics, Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu, Nepal
| | - G S Shrestha
- Department of Anesthesia, Tribhuvan University Teaching Hospital, Nepal
| | - A Sharma
- Department of Paediatrics, Nepal Medical College and Teaching Hospital, Jorpati, Kathmandu, Nepal
| |
Collapse
|
32
|
Aryal D, Acharya SP, Shrestha GS, Goffi A, Hawryluck L. Nepal after the disaster. Insider points of view for the future of critical care medicine. Am J Respir Crit Care Med 2016; 192:781-4. [PMID: 26176763 DOI: 10.1164/rccm.201507-1346ed] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Diptesh Aryal
- 1 Department of Anesthesiology Tribhuvan University Teaching Hospital Kathmandu, Nepal
| | - Subhash P Acharya
- 1 Department of Anesthesiology Tribhuvan University Teaching Hospital Kathmandu, Nepal
| | - Gentle S Shrestha
- 1 Department of Anesthesiology Tribhuvan University Teaching Hospital Kathmandu, Nepal
| | - Alberto Goffi
- 2 Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, Ontario, Canada
| | - Laura Hawryluck
- 2 Interdepartmental Division of Critical Care Medicine University of Toronto Toronto, Ontario, Canada
| |
Collapse
|
33
|
Shrestha RK, Shrestha GS. Assessment of Color Vision Among School Children: A Comparative Study Between The Ishihara Test and The Farnsworth D-15 Test. JNMA J Nepal Med Assoc 2015; 53:266-269. [PMID: 27746468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION Color vision is one of the important attribute of visual perception. The study was conducted at different schools of Kathmandu to compare the findings of the Ishihara Pseudoisochromatic test and the Farnsworth D-15 test. METHOD A cross-sectional study was conducted among 2120 students of four schools of Kathmandu. Assessment included visual acuity measurement, slit lamp examination of anterior segment and fundus examination with direct ophthalmoscopy. Each student was assessed with the Ishihara pseudoisochromatic test and the Farnsworth D-15 test. The Chi-square test was performed to analyse color vision defect detected by the Ishihara test and the Farnsworth D-15 test. RESULTS A total of 2120 students comprising of 1114 males (52.5%) and 1006 females (47.5%) were recruited in the study with mean age of 12.2 years (SD 2.3 years). The prevalence of color vision defect as indicated by the Ishihara was 2.6 and as indicated by the D-15 test was 2.15 in males. CONCLUSION For school color vision screening, the Ishihara color test and the Farnsworth D-15 test have equal capacity to detect congenital color vision defect and they complement each other.
Collapse
Affiliation(s)
- R K Shrestha
- Department of Opthalmology, Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal
| | - G S Shrestha
- Department of Ophthalmology, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
34
|
Sharma Poudyal B, Gyawali B, Tuladhar S, Kapali K, Shrestha GS. Inspiration amidst the challenges: the first report of successful bone marrow transplantation in the Himalayan country Nepal. Br J Haematol 2015; 173:941-2. [PMID: 26303869 DOI: 10.1111/bjh.13645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Bishesh Sharma Poudyal
- Clinical Haematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal.,Department of Haematology, Nobel Hospital, Kathmandu, Nepal
| | - Bishal Gyawali
- Department of Clinical Oncology and Chemotherapy, Nagoya University Hospital, Nagoya, Japan.
| | - Sampurna Tuladhar
- Department of Pathology and Clinical Haematology Unit, Civil Service Hospital, Kathmandu, Nepal
| | - Kabita Kapali
- Department of Haematology, Nobel Hospital, Kathmandu, Nepal
| | - Gentle S Shrestha
- Intensive Care Unit, Tribhuwan University Teaching Hospital, Kathmandu, Nepal
| |
Collapse
|
35
|
Shrestha GS, Shrestha N, Shrestha BK, Shrestha PS. Anaesthetic Management of Patients with Takayasu's Arteritis for Open Cholecystectomy. JNMA J Nepal Med Assoc 2015; 53:144-147. [PMID: 26994039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023] Open
Abstract
Takayasu's arteritis is a well known yet rare form of large vessel vasculitis.1 This inflammatory disease often affects the ascending aorta and aortic arch, causing obstruction of the aorta and its major arteries.2 Anaesthetic management for these patients is complicated by severe hypertension, end-organ dysfunction, stenosis of major blood vessles and difficulties in monitoring blood pressure.1 We present two patients who underwent open cholecystectomy under neuraxial anaesthesia. We have discussed about various perioperative issues and their management.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anesthesiology, IOM, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - N Shrestha
- Department of Anesthesiology, IOM, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - B K Shrestha
- Department of Anesthesiology, Sahid Gangalal National Heart Center, Kathmandu, Nepal
| | - P S Shrestha
- Department of Anesthesiology, IOM, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| |
Collapse
|
36
|
Parajuli BD, Shrestha GS, Pradhan B, Amatya R. Comparison of acute physiology and chronic health evaluation II and acute physiology and chronic health evaluation IV to predict intensive care unit mortality. Indian J Crit Care Med 2015; 19:87-91. [PMID: 25722550 PMCID: PMC4339910 DOI: 10.4103/0972-5229.151016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context: Clinical assessment of severity of illness is an essential component of medical practice to predict the outcome of critically ill-patient. Acute Physiology and Chronic Health Evaluation (APACHE) model is one of the widely used scoring systems. Aims: This study was designed to evaluate the Performance of APACHE II and IV scoring systems in our Intensive Care Unit (ICU). Settings and Design: A prospective study in 6 bedded ICU, including 76 patients all above 15 years. Subjects and Methods: APACHE II and APACHE IV scores were calculated based on the worst values in the first 24 h of admission. All enrolled patients were followed, and outcome was recorded as survivors or nonsurvivors. Statistical Analysis Used: SPSS version 17. Results: The mean APACHE score was significantly higher among nonsurvivors than survivors (P < 0.005). Discrimination for APACHE II and APACHE IV was fair with area under receiver operating characteristic curve of 0.73 and 0.79 respectively. The cut-off point with best Youden index for APACHE II was 17 and for APACHE IV was 85. Above cut-off point, mortality was higher for both models (P < 0.005). Hosmer–Lemeshow Chi-square coefficient test showed better calibration for APACHE II than APACHE IV. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.748 (P < 0.01). Conclusions: Discrimination was better for APACHE IV than APACHE II model however Calibration was better for APACHE II than APACHE IV model in our study. There was good correlation between the two models observed in our study.
Collapse
Affiliation(s)
- Bashu Dev Parajuli
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gentle S Shrestha
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Bishwas Pradhan
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Roshana Amatya
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
37
|
Shrestha GS, Poudyal B, Bhattarai AS, Shrestha PS, Sedain G, Acharya N. Perioperative management of two cases of hemophilia with spontaneous intracerebral hemorrhage undergoing emergency craniotomy in resource constrained setup of Nepal. Indian J Crit Care Med 2014; 18:754-6. [PMID: 25425844 PMCID: PMC4238094 DOI: 10.4103/0972-5229.144023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Patients with hemophilia are prone to develop spontaneous intracranial hemorrhage. It carries a significant risk of morbidity and mortality. In this case series, we report two cases of hemophilia who suffered spontaneous intracerebral hemorrhage with features of raised intracranial pressure and were successfully managed perioperatively. The patients were managed with early intensive care unit management, measures to reduce intracranial pressure, perioperative clotting factor administration, airway management and surgery to decrease the raised intracranial pressure. Both patients improved following surgery and were discharged home. Perioperative multidisciplinary management of hemophilia is discussed in this series.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal ; Department of Anaesthesiology, Alka Hospital Pvt. Ltd., Jawalakhel, Lalitpur, Nepal
| | - B Poudyal
- Department of Internal Medicine, Civil Service Hospital, Kathmandu, Nepal
| | - A S Bhattarai
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - P S Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - G Sedain
- Department of General Surgery, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - N Acharya
- Department of Internal Medicine, Civil Service Hospital, Kathmandu, Nepal
| |
Collapse
|
38
|
Shrestha GS. Bedside sonographic evaluation of the diaphragm in ventilator dependent patients with amyotrophic lateral sclerosis. A report of two cases. Nepal Med Coll J 2014; 16:95-98. [PMID: 25799822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease with progressive and inexorable loss of bulbar and limb functions. Respiratory muscle weakness and failure is a common complication late in the course of disease. Bedside ultrasonography of the diaphragm was done in two ventilator dependent patients with ALS. Thickness of the diaphragm was markedly reduced during both end expiration and end of deep inspiration. The degree of diaphragmatic thickening was also significantly reduced. The diaphragmatic excursion during deep inspiration was sub-optimal. The findings were consistent with diaphragmatic atrophy and paralysis. Sonography of the diaphragm can be a useful non-invasive bedside tool for the diagnosis and follow up of diaphragmatic involvement in patients with amyotrophic lateral sclerosis.
Collapse
|
39
|
Abstract
INTRODUCTION In April 2006, the people of Nepal organised mass demonstrations demanding the restoration of democracy in the country. The ocular injuries that resulted during the riots that ensued, their pattern and the visual outcome of the injured have not yet been reported. OBJECTIVE To study the demographic profile, type, severity and the visual outcome of ocular injuries that occurred during the 2006 people's uprising in Nepal. SUBJECTS AND METHODS This was a retrospective interventional series of cases involving 29 subjects. The main outcome measures were demography, laterality of injury, type of injury and the visual status before and after the trauma. RESULTS The age of the victims ranged from 14 to 32 years. Among the victims with eye injuries, 27 (93.1 %) were males, who were unemployed youth, students and construction workers. The left eye was injured more frequently than the right. Non-lethal bullets and explosive tear gas were the commonest agents of the major ocular injuries. The main types of injuries requiring hospitalization were closed globe injuries in eight victims and open globe in six. Surgical intervention was required in 57.2 % (n = 29) of the cases. The visual outcome was poor in cases of open globe injury with posterior segment involvement. CONCLUSION Non-lethal bullets and explosive tear gases can cause significant visual impairment. Severe open globe injury with a retained intra-ocular foreign body is associated with significant visual loss.
Collapse
Affiliation(s)
- A K Sharma
- BP Koirala Lion's Centre for Ophthalmic Studies, IOM, Kathmandu, Nepal
| | | | | | | | | |
Collapse
|
40
|
Amatya A, Marhatta MN, Shrestha GS, Shrestha A, Amatya A. A comparison of midazolam co-induction with propofol priming in propofol induced anesthesia. J Nepal Health Res Counc 2014; 12:44-48. [PMID: 25574984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Combination therapy with two or more different drugs, with the intension of reaching the same therapeutic goal, was heavily criticized for a long time. However, it is accepted today, especially when advantage over monotherapy can be proved. Our study was undertaken to compare whether propofol priming and midazolam predosing would affect total induction dose requirement of Propofol. METHODS A prospective randomized, double blind control study was conducted where 120 patients (16-65 years) were divided into 3 groups. Group P received 0.4 mg/kg of Propofol, Group M received 0.05 mg/kg of Midazolam and Group N received 3 ml of Normal Saline 5 minutes after intravenous pethidine 0.75 mg / kg given for analgesia. We compared the total dose of propofol requirement for induction of anaesthesia in all the 3 groups, taking loss of verbal contact as the end point. Additionally, changes in haemodynamic status like blood pressure and heart rate at various intervals were studied and compared among the groups. RESULTS The groups were similar in terms of age, sex, weight and American Society of Anesesthesiologists Physical Status.The dose of Propofol required to induce anesthesia in Midazolam group was 1.58 mg/kg,1.86 mg/kg in Propofol group and 1.96 mg/kg in the control group. There were less hemodynamic changes in Midazolam group compared to the other two. CONCLUSIONS Pre-dosing with Midazolam is more effective than Propofol priming in reducing the dose of Propofol induced anaesthesia associated with minimum hemodynamic alterations.
Collapse
Affiliation(s)
- A Amatya
- Department of Anesthesiology, Shahid Gangalal Nationl Heart Centre, Bansbari
| | - M N Marhatta
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - G S Shrestha
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - A Shrestha
- Department of Anesthesiology, Tribhuvan University Teaching Hospital, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| | - A Amatya
- Department of Community Medicine and Public Health, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
| |
Collapse
|
41
|
Abstract
Dermatomyositis is an idiopathic inflammatory myopathy with involvement of muscle, skin and other organs. Valvular heart disease increases the risk of perioperative adverse cardiac events. Only a little information is available about the anaesthetic management of a patient with dermatomyositis and valvular heart disease. Here we considered combined spinal-epidural technique for total abdominal hysterectomy, minimizing the risk of delayed recovery from muscle relaxants, aspiration pneumonitis, arrhythmias and cardiac failure.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology, Institute Of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
| | | |
Collapse
|
42
|
Shrestha GS, Marhatta MN, Amatya R. Use of gabapentin, esmolol or their combination to attenuate haemodynamic response to laryngoscopy and intubation. Kathmandu Univ Med J (KUMJ) 2011; 9:238-243. [PMID: 22710530 DOI: 10.3126/kumj.v9i4.6336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Laryngoscopy and intubation increases blood pressure and heart rate. OBJECTIVE The study aims to investigate the effect and safety of gabapentin, esmolol or their combination on the haemodynamic response to laryngoscopy and intubation. METHODS A total of 72 patients undergoing elective surgery were randomly allocated to one of the four groups. First study drug was administered orally as gabapentin 1200mg or placebo. Second study drug was administered intravenously as esmolol 1.5mg/ kg or normal saline. Heart rate, rate pressure product, systolic blood pressure and mean arterial pressure were recorded at baseline and at zero, one, three and five minutes after tracheal intubation. RESULTS Baseline values were compared with the values at various time intervals within the same group. In group PE (placebo, esmolol), there was significant decrease in heart rate and rate pressure product at five minutes. In group GN (gabapentin, normal saline), there was significant decrease in systolic blood pressure and mean arterial pressure at five minutes. In group GE (gabapentin, esmolol), there was significant decrease in heart rate at zero, three and five minutes. Systolic blood pressure, mean arterial pressure and rate pressure product was significantly lower at three and five minutes. In group PN (placebo, normal saline), there was significant increase in heart rate at zero, one, three and five minutes; systolic blood pressure at zero and one minutes; mean arterial pressure at zero and one minutes and rate pressure product at zero, one and three minutes. In group GN (gabapentin, normal saline), there was significant increase in heart rate at zero, one and three minutes and rate pressure product at zero, one and three minutes. In group PE (placebo, esmolol), there was significant increase in systolic blood pressure at zero and one minutes and mean arterial pressure at zero and one minutes. However, in group GE (gabapentin, esmolol) none of the variables showed statistically significant increase at any time. Inter-group comparison was made for each time point. At zero minute, there was significant difference in heart rate between groups PN and GE, GN and PE and GN and GE Significant difference was also noted in rate pressure product between PN and GE at zero minute. At one minute there was difference in heart rate between PN and PE, PN and GE, GN and PE and between GN and GE. Significant difference was observed in rate pressure product between PN and PE amd between PN and GE at one minute. No significant side effects of the study drugs were observed. CONCLUSIONS Combination of gabapentin and esmolol in this study design is safe and better attenuates both the pressor and tachycardic response to laryngoscopy and intubation, than either agent alone.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital Maharajgunj, Kathmandu, Nepal.
| | | | | |
Collapse
|
43
|
Shrestha GS, Sah RP, Amatya AG, Shrestha N. Anaesthetic management of patients with Xeroderma pigmentosum. A series of three cases. Nepal Med Coll J 2011; 13:231-232. [PMID: 22808824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Xeroderma pigmentosum is a rare autosomal recessive disorder with clinical and cellular hypersensitivity to ultraviolet radiation and defective DNA repair. Skin cancer, mainly on the face, head or neck is very common. Inhalational anaesthetic agents and muscle relaxants are best avoided due to the possibility of inducing DNA damage and prolonged effects of muscle relaxants. These patients may have a difficult airway. These patients may have immature brain development which may render them sensitive to synergistic effect of benzodiazepines and opioids as seen in the first case. Total intravenous anaesthesia is preferred. Nonsteroidal anti inflammatory agents and opioids for multimodal analgesia may be beneficial.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
| | | | | | | |
Collapse
|
44
|
Abstract
OBJECTIVE The study was conducted to evaluate tear film stability and tear secretion before and after laser in situ keratomileusis. MATERIALS AND METHODS It was a prospective, longitudinal and non-comparative analysis of clinical data of 20 consecutive myopic patients (40 eyes) collected before and after laser in situ keratomileusis. Assessments included tear secretion (Schirmer I and II), fluorescein tear break up time and ocular surface staining. STATISTICS The statistical package for social science (SPSS 10.0) was used for data analysis. The parameters of tear secretion and tear stability were analyzed using the paired and unpaired Student t-tests. RESULTS Schirmer II was reduced at seven days (9.5 ± 4.30 mm) and one month (10.3 ± 3.06 mm, p=0.001) after operation from the pre-operative value of 16.12 ± 3.90 mm. Tear film stability significantly decreased at seven days (6.79 ± 3.05 sec, p Less than 0.001) and one month (8.03 ± 2.81secs, p less than 0.001) from its pre-operative value (12.68 ± 2.69 secs). 87.5% had tear film instability (FBUT less than 10secs) seven days after surgery; it was reduced to 75 % at one month and 27.5 % at three months. It was 7.5 % before surgery. Corneal staining score was increased significantly at seven days (1.42 ± 1. 58, p less than 0.01) and one month (0.95 ± 1.41, p=0.02), from the pre-operative score of 0.17 ± 0.44. CONCLUSION Laser in situ keratomileusis significantly alters the tear film stability, Schirmer values and corneal staining at least for three months.
Collapse
Affiliation(s)
- G S Shrestha
- Institute of Medicine, Tribhuvan University, Maharajgunj, Kathmandu, Nepal.
| | | | | |
Collapse
|
45
|
Shrestha GS, Gurung R, Amatya R. Comparison of Acute Physiology, Age, Chronic Health Evaluation III score with initial Sequential Organ Failure Assessment score to predict ICU mortality. Nepal Med Coll J 2011; 13:50-54. [PMID: 21991703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Critically ill patients are provided with highest level of monitoring, care and treatment in Intensive Care Unit (ICU), which is very expensive and consumes many hospital resources. Various scoring systems have been developed to predict outcome in ICU patients so as to help physicians to prioritize patient admission and management. The objective of this study was to compare Acute Physiology and Chronic Health Evaluation (APACHE) III score with initial Sequential Organ Failure Assessment (SOFA) score to predict ICU mortality. Hundred seventeen patients admitted consecutively in ICU were enrolled. APACHE III and initial SOFA score of individual patients were calculated based on worst values in first 24 hours of admission. Outcome was recorded as survivors or non survivors in ICU. Both the scores were significantly higher in non survivors (p<0.001). A positive and strong correlation was seen between the scores with Spearman's rho correlation coefficient of 0.866 (p<0.001). Discrimination for APACHE III and initial SOFA score was good with area under ROC curve of 0.895 and 0.879 respectively. Cut off point with best Youden index was e" 61 for APACHE III and e" 8 for initial SOFA score. ICU mortality differed significantly above and below cut off points (p<0.001). Hosmer Lemeshow test showed initial SOFA score to have better calibration than APACHE III score. Initial SOFA score is comparable to APACHE III score for mortality prediction in ICU and so can be helpful for better utilization of limited resources in ICU.
Collapse
Affiliation(s)
- G S Shrestha
- Department of Anaesthesiology, Institute of Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal.
| | | | | |
Collapse
|
46
|
Abstract
A case of congenital isolated coloboma of both the upper lids from just lateral to the lacrimal punctum up to the medial half, with symblepharon in the region of lower eyelid, was studied in a 7-year-old female child. She did not have any other associated anomalies. The birth and family histories were normal. The puncta were normal in position and well apposed to the globe. The closure of the lid coloboma was done by release of symblepharon along with direct closure of the defect, for the right eye first, and one month later, for the left eye. DOI: http://dx.doi.org/10.3126/nepjoph.v4i1.5877 NEPJOPH 2012; 4(1): 194-196
Collapse
|