Qatar Medical Journal - 2 - Qatar Critical Care Conference Proceedings, February 2020

Dr. Ibrahim Fawzy Hassan

Local Host and QCCC 2019 Conference Chair

Dear Friends and Colleagues,

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

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

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

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

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

Prof. Guillaume Alinier

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

Dear Contributors and Conferences Delegates,

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

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

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

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

Critical care is a multidisciplinary and interprofessional specialty providing comprehensive care to patients in an acute life-threatening, but treatable condition.¹ The aim is to prevent further physiological deterioration while the failing organ is treated. Patients admitted to a critical care unit normally need constant attention from specialist nursing and therapy staff at an appropriate ratio, continuous, uninterrupted physiological monitoring supervised by staff that are able to interpret and immediately act on the information, continuous clinical direction and care from a specialist consultant-led medical team trained and able to provide appropriate cover for each critical care unit, and artificial organ support and advanced therapies which are only safe to administer in the above environment. It is an important aspect of medical care within a hospital as it is an underpinning service without which a hospital would not be able to conduct most or all of its planned and unplanned activities. As such, critical care requires a very intensive input of human, physical, and financial resources.² It occupies a proportionately large fraction of a hospital's estate and infrastructure for a small number of patients. The resources that are invested into a critical care bed should therefore be valued against the activities and care throughout the hospital that the availability of that bed allows to happen. Given that demand for critical care beds will continue to grow, providing more critical care beds is unlikely to work on its own since experience has shown that additional capacity is soon absorbed within routine provision.³ Attention must therefore be given to maximising the efficient and effective use of existing critical care beds, necessitating an ability to cope with peaks in demand.

Historically the world over, the development of critical care units has been unplanned and haphazard and largely relied on the interest of local clinicians to drive development. However, there is now an eminent body of opinion that supports an alternative approach to critical care provision – namely through a managed Critical Care Network with an agenda of integrated working and the focus on facilitating safe quality care that is cost-effective and patient-focused for acutely and critically ill patients across the various constituent organisations of a healthcare system.

The Critical Care Service in Hamad Medical Corporation (HMC) has developed rapidly to address the increasing demand linked to the population growth in the State of Qatar with the aim of meeting the vision of the National Health Strategy (NHS). It is paralleled with HMC's vision to improve the delivery of critical care to patients and their families in a way that meets the highest international standards such as those set by the Joint Commission International by whom the Corporation has been accredited since 2007.⁴ For this reason, the organisation took the lead to perform a gap analysis with expert auditors from the United States of America and the United Kingdom who have experience in critical care service provision. The aim was to assess the Critical Care Service within HMC and identify potential short-term, medium-term, and long-term opportunities for improvement. This assessment focused on a very broad range of aspects such as: bed capacity, facilities and equipment, medical, nursing and allied healthcare staffing levels and their education, career development pathways, patient safety, quality metrics, clinical governance structure, clinical protocols and pathways, critical care outreach, and future planning for critical care at HMC.

As a result of extensive review for the Critical Care Services at HMC, the Critical Care Network (CCNW) in the State of Qatar was established in 2014. It is a strategic and operational delivery network, which includes 12 hospitals across the country. The network functions through a combination of strategic programmes, working groups, and large multidisciplinary governance and professional development events. Through collaborative working with the leadership of the various facilities and critical care clinicians, the network reviews services and makes improvements where they are required, ensuring delivery of patient-focused care by appropriately educated and trained healthcare professionals as well as the appropriate utilisation of critical care beds for those patients who require such care. Detailed involvement and engagement from the clinical membership at every event and in the various working groups ensures that all decisions, reports, and improvement programmes are clinically-focused and benefit from a diversity of opinions that can be considered for implementation. All of this is carefully aligned to the requirements of the latest Qatar National Health Strategy.⁵

It aims to adopt evidence-based best practices to deliver the safest, most effective and most compassionate care to our critical care patients by setting the most appropriate care pathway to transform Critical Care Services across HMC hospitals. The key aims of the CCNW as stated in its Terms of Reference document are listed in Table 1.⁶ This enhances the quality and safety of patient care across HMC, promotes staff satisfaction, and improves customer service and patient outcome. The CCNW is structured in a way that involves all Critical Care Service stakeholders to maintain the stability and sustainability of delivering the best care to critically ill patients.

The CCNW is steered by a multidisciplinary committee (Figure 1) that is empowered with the generative, managerial, and fiscal responsibilities to enable the required changes to take place. The committee oversees the HMC Critical Care Services through coordinating and standardising their activities and governance arrangements across the complete HMC healthcare system. It provides HMC clinical and managerial leadership at a corporate and local level, the opportunity to jointly develop critical care standards, policies, and operating procedures. In doing so, the CCNW decides on and implements recommendations on how to best plan and deliver critical care services using evidence-based practice set against the context of national and international practices. The HMC CCNW gives recommendations to various committees to improve the services in the following areas:

1. Defining the level of care and critical care core standards for HMC: The CCNW standardises critical care across the Corporation regardless of where it is being delivered. As such it develops the critical care core standards for the critical care units and gives recommendations regarding future critical care core facility planning within HMC. The CCNW helps the Ministry of Public Health (MoPH) develop the National Critical Care Core Standards. 2. Quality and safety: The CCNW works collaboratively with HMC leaders to ensure a culture of quality is embedded within all critical care services delivered within HMC. There is a continuous evaluation process in place to measure the quality of care for high performance critical care which is the goal. This is based upon ongoing observations, robust data collection and analysis, and a change management strategy implemented as required. 3. Clinical pathways, guidelines, and protocols: The CCNW develops, according to international best practice, clinical care pathways, guidelines, and protocols that govern critical care units throughout HMC. Critical care clinical practice is audited against these standards, compared with the international benchmark, and updated as required to ensure currency of all patient care aspects. 4. Transfer and transportation of critically ill patients: The CCNW develops HMC-wide criteria for patient intramural, extramural, and international transfers, and sets standards of care during transportation in collaboration with the HMC Ambulance Service Transfer and Retrieval team. This includes HMC-wide bed management consideration with the senior consultants on call, review of the patient's condition and medical needs, and assessment of the mission associated risks and mitigating strategies. This involves significant planning on the part of the team, clear communication and handovers, and the use of checklists at several stages to ensure the provision of safe and efficient patient transfers. 5. Education: The CCNW develops educational plans and ensures corresponding courses accredited by the Qatar Council for Healthcare Practitioners (QCHP) are designed and delivered to address the training needs of clinicians. The portfolio of courses is regularly reviewed to meet identified needs so clinicians always possess the appropriate knowledge and skills to manage critically ill patients. 6. Research and Critical Care Data Registry development: Being a key player in an Academic Health System, HMC fosters a relatively young but growing research environment⁴ of which the CCNW forms an integral part. Creating opportunities for epidemiological research and also fulfilling the needs for quality monitoring and benchmarking, the CCNW has enabled the creation of critical care data registries. Such registries provide a valuable source of information and have already been exploited at HMC to better understand the type of patients a service cares for and patient outcomes with respects various factors.⁷

The establishment of a CCNW at a corporate level (with membership from local leaders across HMC) has provided a level of oversight and leadership which has significantly contributed to optimizing and reshaping the way acutely ill patients are cared for. It has enabled the adoption of evidence-based best practices across the various critical care services of HMC as well as created a multidisciplinary forum for dialogue and collaboration. Innovative work focusing on providing effective, up-to-date, and patient-focused care are ongoing as well as HMC's pursuit of various international accreditation awards by prestigious organisations and professional bodies.

Bjorn Ibsen, an anesthetist who pioneered positive pressure ventilation as a treatment option during the Copenhagen polio epidemic of 1952, set up the first Intensive Care Unit (ICU) in Europe in 1953. He managed polio patients on positive pressure ventilation together with physicians and physiologists in a dedicated ward, where one nurse was assigned to each patient. In that sense Ibsen is more or less the father of intensive care medicine as a specialty and also an advocate of the one-to-one nursing ratio for critically ill patients.

Nowadays, the Surgical Intensive Care Unit (SICU) offers critical care treatment to unstable, severely, or potentially severely ill patients in the perioperative setting, who have life-threatening conditions and require comprehensive care, constant monitoring, and possible emergency interventions. Hence there is one very specific challenge in the surgical setting: the intensivist has to manage the patient flow starting from admission to the hospital through to the operating theater, in the SICU, and postoperatively for the discharge to the ward. In other words, the planning of the resources (most frequently availability of beds) has to be optimized to prevent cancellations of elective surgical procedures but also to facilitate other emergency admissions. SICU intensivists take the role of arbitrators between surgical demand and patient's interests. This means they supervise the safety, efficacy, and workability of the process with respect to all stakeholders. This notion was reported in 2007 when Stawicki and co-workers performed a small prospective study concluding that it appears safe if the dedicated intensivist takes over the role of the last arbitrator supported by a multidisciplinary team.¹

However, demographic changes in many countries during the last few decades have given rise to populations which are more elderly and sicker than before. This impacts on the healthcare system in general but on the intensivist and the ICU team too. In addition, in a society with an increased life expectancy, the balance between treatable disease, outcome, and utilization of resources must be maintained. This fact gains even more importance as patients and their families claim “high end” treatment.

Such a demand is reflected looking at the developments that have taken place over the last 25 years. Mainly, the focus of intensive care medicine was on technical support or even replacement of failing organ systems such as the lungs, the heart, or the kidneys by veno-venous extracorporeal membrane oxygenation (VV-ECMO), veno-arterial ECMO (VA-ECMO), and continuous veno-venous hemofiltration (CVVH) respectively. This means “technical care” became a core capability and expectation of critical care medicine. In parallel, medical treatment became more standardized. For example, lung protective ventilation strategies, early enteral feeding, and daily sedation vacation are part of modern protocols. As a consequence, ventilator time has been reduced and patients therefore develop delirium less frequently. These measures, beside others, are implemented in care bundles to improve the quality of care of patients by the whole ICU team.

The importance of specialty trained teams was already pointed out 35 years ago when Li et al.,² demonstrated in a study performed in a community hospital that the mortality was decreased if an ICU was managed 24/7 by an on-site physician. The association of improved outcomes and presence of a critical care trained physician (intensivist) has been shown in several studies since that time.^3,, ^4,, ^5,, ⁶ A modern multidisciplinary critical care team consists at least of an intensivist, ICU nurse, pharmacist, respiratory therapist, physiotherapist, and the primary team physician. Based on clinical needs, the team can be supplemented by oncologists, cardiologists, or other specialties. Again, this approach is supported by research: a recent retrospective cohort study from the California Hospital Assessment and Reporting Taskforce (CHART) on 60,330 patients confirmed the association between improved patient outcome and such a multidisciplinary team.⁷

If such an intensive care team makes a difference, why do not all patients at risk receive advanced ICU-care? It was already demonstrated by Esteban et al., in a prospective study that patients with severe sepsis had a mortality rate of 26% when not admitted to an ICU in comparison to 11% when they were admitted to an ICU.⁸ Meanwhile, we know that early referral is particularly important, because for ischemic diseases the timing appears to make a difference in terms of full recovery.

So, the following questions arise: Should intensive care be rolled out to each ward and physical admission to an ICU or be restricted to special cases only? For this purpose, the so-called “Rapid Response Teams” (RRT) or “Medical Emergency Team” (MET), which essentially are a form of an ICU outreach team, were implemented. The name, composition, or exact role of such team varies from institution to institution and country to country. Alternatively, should all ward staff be educated to recognize sick patients earlier for a timely transfer to a dedicated area? This would mean that ICU-care would be introduced in the ward.

A first attempt to answer this question, whether to deploy critical care resources to deteriorating patients outside the ICU 24/7, was given by Churpek et al.⁹ The success of the rapid response teams could be related to decreased rates of cardiac arrest outside the ICU setting and in-hospital mortality. Interestingly, an analysis of the registry database of the RRT calls in this study showed that the lowest frequency of calls occurred between 1:00 AM to 6:59 AM time period. In contrast, the mortality was highest around 7 AM and lowest during noon hour. This indicates that not simply the availability of such a team makes a difference but also the alertness of the ward-teams is of high importance to identify deteriorating patients in a timely manner. Essentially, this would necessitate ward staff being trained to provide a higher level of care enabling them to better recognize when patients become sicker to avoid a delayed call to the ICU.

Alternatively, a system in which the intensivist plays a major role in daily ward rounds could be beneficial. So, the ward doctor should become an intensivist. However, the latter means the ICU is rolled out across the whole hospital which would consume a huge amount of resources.

Another option would be 24/7 remote monitoring of patients at risk that notifies the intensivist or RRT in case of need. The infrastructure, technology, and manpower to put this in place also has associated costs.

As the demand for ICU care will rise further in the future, intensivists will play an even more important role in the healthcare system that itself is under enormous economic pressure to ensure the best quality of care for critically ill patients. Besides excellent knowledge and hard skills, intensivists need to be team players, communicators, facilitators, and arbitrators to achieve the best results in collaboration with all involved in patient treatment.

Background: Sepsis, a medical emergency and life-threatening disorder, results from abnormal host response to infection that leads to acute organ dysfunction¹. Sepsis is a major killer across all ages and countries and remains the most common cause of admission and death in the Intensive Care Unit (ICU)². The true incidence remains elusive and estimates of the global burden of sepsis remain a wild guess. One study suggested over 19 million cases and 5 million sepsis-related deaths annually³. Addressing the challenge, the World Health Assembly of the World Health Organisation (WHO) passed a resolution on better prevention, diagnosis, and management of sepsis⁴. Current state of sepsis guidelines: Despite thousands of articles and hundreds of trials, sepsis remains a major killer. The cornerstones of sepsis care remain early recognition, adoption of a systematic evidence-based bundle of care, and timely escalation to higher level of care. The bundle approach has been advocated since 2004 but underwent major modifications in subsequent years with more emphasis on the time-critical nature of sepsis and need to restore physiological variables within one hour of recognition. A shift from a three and six-hour bundle to one-hour bundle has been recommended⁵. This single hour approach has been faced with an outcry and been challenged^6–8. One size never fits all: Over several decades, the individual components of the sepsis bundle have not changed. Encountering a patient with suspected sepsis, one should measure lactate, obtain blood cultures, swiftly administer broad spectrum antimicrobials and fluids, and infuse vasopressors. A critical question arises: should we do this for all patients? Sepsis is not septic shock and guidelines did not make distinctive recommendations for each. Septic patients will present differently with some having more subtle signs and symptoms. Phenotypically, we do not know which patient with infection will develop a dysregulated host response and will succumb to sepsis and/or shock^6–8. The existing bundle lacks high quality evidence to support its recommendations and a blanket implementation for all patients with ‘suspected’ sepsis could be harmful⁷. Indeed, a significant reduction of sepsis and septic shock in Australia and New Zealand was observed in a bundle-free region⁸. Emergency Department (ED) challenges: Upon arrival in the ED, patients will be triaged. This is ‘time zero’⁵. Those with hypotension and hypoperfusion will be easily recognised and at most need to receive emergent care. Sepsis, per se, may not manifest clear cut signs and expertise to identify it is required. Those with non-specific symptoms may trigger an early warning scoring system and receive unnecessary antimicrobials and a large volume of intravenous (IV) fluids. Both therapies are not without significant side effects. Putting pressure on ED physicians to implement the 60-minute bundle without individualisation of care puts our patients at risk^6–8. Diagnostic challenges: Given the heterogenous nature and diverse pathobiological pathways, sepsis diagnosis can be challenging and both over and under-treatment can result. Established biomarkers such as procalcitonin and C-reactive protein lack specificity to rule out infection as the cause of inflammation. Currently, no laboratory test or biomarker helps predict which patients with infection or inflammation will develop organ dysfunction. A dire need for a specific sepsis biomarker exists¹⁰.

Modern molecular-based technologies are evolving and utilise polymerase chain reaction (PCR), nanotechnology, and microfluidics for point-of-care testing. Some devices identify causative microorganisms and their sensitivity in less than an hour¹⁰. The bundle components: Catecholamines along with IV fluids are indicated to restore perfusion. However, inadvertent side effects may arise, especially at higher doses. Anti-adrenergic ß-blockers improve cardiac performance, enhance receptor responsiveness, and possess anti-inflammatory action. All are desirable in patients with septic shock¹¹.

One randomised trial showed beneficial and protective effects of ß-blockers in septic shock. Rapidly acting titratable agents should be used in conjunction with appropriate hemodynamic monitoring and after adequate volume resuscitation. There is no consensus on target heart rate but an arbitrary cut off of 80–95 beats per minute is reasonable¹¹.

Fluid resuscitation is the cornerstone of sepsis management. There is also compelling evidence that too much fluid is bad. Starch-based colloids should not be used in septic shock. Albumin is an alternative when large volumes are required but is not appropriate in traumatic brain injury. Balanced, less chloride and less acidic crystalloids are safer for the kidneys and are preferred over normal saline. Doses of IV fluids should be tailored to the patient's condition and a 30 ml/kg recommendation should be reviewed.¹²

Effective sepsis management requires adequate dosing of antimicrobials. Significant alteration of pharmacokinetics and pharmacodynamics is characteristic of septic shock¹³. Accurate and effective dosing is challenging particularly in patients with multiple comorbidities and those receiving extracorporeal organ support. Underdosing results in treatment failure, whilst overdosing leads to toxicity and the risk of developing multi-drug resistant organisms¹³. An individualised approach supported by therapeutic drug monitoring is suggested to ensure clinical efficacy¹³. Sepsis research: The search for a cure for sepsis is ongoing. A large prospective, randomised two-arm, parallel group study aims to recruit over 200 patients with septic shock across critical care units in Qatar. Evaluation of Hydrocortisone, Vitamin C, and Thiamine (HYVITS) examines the safety and efficacy of this triple therapy¹⁴. Sepsis in the young patient: Children are particularly vulnerable to sepsis. 1 in 6 children admitted with septic shock to ICU will die. As the majority of paediatric sepsis cases are community acquired, there is a strong need to raise awareness both for families and primary healthcare providers. Akin to adults, a bundle-approach to paediatric sepsis is strongly encouraged. National programs for paediatric sepsis have been established¹⁵. The Qatar paediatric multidisciplinary sepsis program was established under the umbrella of the adult programme in 2017. A structured and standardised approach to sepsis across all neonate and paediatric facilities has been developed and implemented. Improvement in timely sepsis recognition and administration of antimicrobials within the golden hour has been observed. The program aims to achieve a 95% compliance to the paediatric sepsis bundle by the end of 2019. A screening tool and order set have been put in place and are presented in this special issue of Qatar Medical Journal^16,17. Obstetric sepsis: Pregnancy and childbirth are risk factors for sepsis. Multi-organ failure and death can result from puerperal sepsis¹⁸. Sepsis is the direct and leading cause of maternal mortality in the UK¹⁹. Attention to maternal sepsis with a tailored approach is encouraged. The Qatar National Sepsis Program developed a sepsis care pathway for pregnant women and during their early post-partum period. Challenges in low socioeconomic societies: A broader, national –or better yet– a global approach to further sepsis management and outcome should be considered. There are a number of significant challenges to address. One such challenge is the inconsistency of the operational definition and diagnostic approaches for sepsis including coding and documentation^1,3.

Significant deficiencies in healthcare systems have been highlighted by sepsis. This is most obvious in medium- and low-income countries. A major limitation to effective sepsis management is inadequate medical staffing and poor knowledge and awareness of sepsis. Both have a negative impact on sepsis outcome³.

Poor medical facilities in many countries pose significant challenges to sepsis care. Lack of critical care capacity – a global phenomenon – has been linked to poor outcome of sepsis cases and septic shock. This could be attributed to provision of suboptimal critical care, monitoring and critical interventions outside of the ICU. ICU availability is subject to inconsistency and inequity.^2,3

Lack of adequate surgical capacity to accomplish timely source control adversely affects sepsis management. This, unfortunately, in medium- and low-income countries, is accompanied by inadequate medical supplies, diagnostic capacity, and manpower which increases sepsis mortality and morbidity³. Global concerns: Antimicrobials are critical for sepsis care. A global concern is the development of multi-drug resistant organisms and the lack of novel antimicrobials and this adds pressure on those caring for septic patients. Effective antimicrobials should be utilised to eradicate infections. Misuse, inadequacy, inferior agents, and lack of timely access to effective and affordable agents significantly hinders patient's recovery from sepsis^2,3.

Optimum sepsis outcome mandates attention to acute sepsis complications (e.g. acute renal or respiratory failure) as well as addressing post-discharge complications and disability. These challenging issues remain poorly studied or addressed³. Conclusion: Sepsis and septic shock are major global health concerns. Progress has been achieved in understanding this life-threatening syndrome at a biological, metabolic, and cellular level. Efforts should be coordinated to improve sepsis care. Better and more accurate diagnostics are needed and governments are encouraged to invest in sepsis research and care. More integrated, inclusive, and focused research is desperately needed. Public education and increased awareness among primary healthcare providers are also critical to improve sepsis outcome.

Trauma is a leading cause of mortality and morbidity worldwide, and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.¹ In addition, approximately 100 million people are temporarily or permanently disabled every year.² The situation is no different in Qatar, and injury related morbidity and mortality is increasing in the entire region, with road traffic collisions (RTCs) being the most common mechanism.¹

It is well recognized now that trauma care provided in high-volume, dedicated, level-one trauma centers, improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness². However, in general, it usually implies a high-volume of cases, dedicated full-time trauma qualified professionals, a solid pre-hospital system, a multidisciplinary team, and excellent rehabilitation services.

Similarly, critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU), has been shown to improve outcomes, especially for polytrauma patients with traumatic brain injury (TBI).³ In fact, the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU, and that a trauma surgeon be its director.⁴ Furthermore, studies have shown that for TBI, it is not necessary for this ICU to be a neurocritical care unit, but rather it should be a unit that is dedicated to trauma, that has standardized protocols for TBI management.^5,6 In fact, the outcomes are better in the latter, with lower mortality in multiple-injured patients with TBI, when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).³ These benefits were shown to increase, with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.⁷

The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH), at Hamad Medical Corporation (HMC), including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry, as well as previous publications from our Trauma Center,^1,8 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards, respectively.

With respect to HGH, the TICU is part of an integrated trauma program, the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH, striving to achieve the best outcomes, excellence in evidence-based patient care, up to date technology, and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit, emergency and trauma resuscitation unit, TICU, trauma step-down unit (TSDU), inpatient ward, and rehabilitation unit.

The new TICU is a closed 19-bed unit, that was inaugurated in 2016, is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants), along with 24 well-trained and experienced associate consultants or specialists, and fellows and residents in training, as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists, pharmacists, dieticians, physiotherapists, occupational therapists, social workers, case managers, and psychologists). It is supported by all medical and surgical subspecialty services.

It is equipped with the latest state-of-the-art technology and equipment, including ‘intelligent ventilators”, neuro-monitoring devices, ultrasound, point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM), and video airway devices.

The TICU is a teaching unit, linked to the HMC Medical Education department, with presence of fellows, and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU, as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon.

The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date, over 40 physicians from both within, and out of, the trauma department have completed the program. Up to seven fellows, including international candidates, are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery, anesthesia, and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020.

Residents (from general surgery, ER, ENT, plastics, orthopedics, and neurosurgery) rotate (one to three months’ rotations) in the TICU, and are actively part of the clinical team.

There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head, chest, abdominal, pelvic, spine, and orthopedic injuries, or isolated-TBI. Of these patients, 378 were severely injured with an injury severity score (ISS)⁹ greater than 16.

According to previously published data from our Trauma Centre,^1,8 our mortality rates (overall approximately 6-7%, as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world, when looking at similarly sized retrospective studies.

The TICU continues to be an active member of the Critical Care Network of HMC.¹⁰ This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow, clinical practice guidelines, evaluation and procurement of technologies, HMC sepsis program, and in general, taking part in any process that pertains to critical care at HMC.

A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include:

- Decreasing rates of infection in TICU - Score-guided sedation orders to decrease sedation use, ventilator days and length of stay - Reducing blood taking and associated costs - Sepsis alert response and bundle compliance - Medical and surgical management of rib fractures

Similarly, many research projects are taking place in the TICU, in coordination with the Trauma Research program, and often in collaboration with other departments (local and international). Examples of some of the research projects include:

- The “POLAR” study (RCT on Hypothermia in TBI)¹¹ - B-blockers in TBI (RCT-ongoing) - Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing)

The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI,¹² sepsis in TBI patients (ongoing), self-extubation in TBI patients,¹³ safety and efficacy of phenytoin in TBI (ongoing), and optic nerve diameter for predicting outcome in TBI (submitted).

The TICU at HGH is a high-volume, high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel, and utilizes the latest in technology and state-of-the-art equipment.

It performs very well, when compared to other similar units in the world, and achieves a comparable, or even lower mortality rate.

With continued great support from the hospital, corporation administration, and Ministry of Public Health, the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides, as well as perform a high quality and quantity of research, quality improvement initiatives, and educational work, in order for it to be amongst the best trauma critical care units in the world.

Background: Critical care is a clinically complex and resource intensive discipline, the world over. Consequently, the delivery of these services has been compounded by the need to sustain a specialized workforce, while maintaining consistent and high standards.^1,2 The regionalization of critical care resources and the creation of referral networks has been one approach that has led to success in this area.^2–7 However, as steps have been made towards regionalization, so too has the need to transfer patients between facilities in order to access these services. The effects of this are already apparent, where estimates in the United States have found that 1 in 20 patients requiring intensive and critical care resulted in transfer to another facility.² The need for such transfers are equally varied as they are common and include: no critical care facilities at the referring facility; no staffed critical care bed availability at referring facility; requirements for expertise and/or specialists facilitates not available at referring site; and the repatriation of patients back to their original facility.^6,8 An increase in the number of patients requiring the continuation of critical care in-transit has led to a need to expand the borders of traditional intensive care beyond the confines of the hospital. Such a concept fits with the assertions of Peter Safar, a pioneer of modern critical care, who proposed that critical care should not be defined by geographic location, but rather a set of principles designed to deliver appropriate and timely care to patients who need it.⁹Specialised transfer services: The advent and implementation of critical care transfer and retrieval services has been the bridge to this divide, lying at the confluence of prehospital emergency care, in-hospital emergency medicine, and intensive care. Undertaking the transfer of a patient requiring the initiation or continuation of critical care is no simple task. Variations in patient type and severity of their medical condition, as well as the expectations of the transfer team are significant. Reports regarding the transfer of patients ranging from critical neonates, to the multi-comorbid geriatric; with complex underlying surgical and medical diagnoses; involving the concomitant administration of multiple vasoactive and sedative medications; with a variety of oxygenation and ventilation requirements, are commonplace in the literature.^6,8,10–16 Consequently, moving these patients from the safety and security of one facility to another is an immense logistical challenge and fraught with risks. In addition to the severity of the patients underlying condition, limitations in space, personnel and equipment, as well an unpredictable operating environment are several of the potential hazards faced during the transfer of these patients.

These hazards are evident in the incidence of adverse events found in the literature. Incorrect referral triage; inadequate transfer team; patients requiring stabilization prior to transfer; equipment and/or technical failures; adverse drug events and medication errors are amongst the most common reported events.^6,8,10–17

Further to this, the movement of patients alone has in itself been shown to have an impact on a patient's baseline status, without the occurrence of negative or untoward events.^10,13,15,16 As a result, patient safety and quality of care have become essential components of modern critical care transfer and retrieval services, with the role of clinical audit central to their ability to learn and improve from previous cases and events. The local solution: Despite the relatively small size of the State of Qatar, critical care transfer and retrieval has nonetheless become a necessity within the country's healthcare system. Figure 1 highlights the locations of the main hospitals. Starting in 2014, a dedicated program was initiated to facilitate the transfer and retrieval of critical care patients across the country.¹⁸ The Specialized High Acuity Adult Retrieval Program (SHAARP) is a joint initiative between the Hamad Medical Corporation Ambulance Service (HMCAS) and the Hamad Medical Corporation (HMC) Critical Care Network (CCN). It consists of a single dedicated purpose-built ambulance, manned and run 24 hours a day, seven days a week by a variety of staff from both HMCAS and the CCN and deployed primarily for the transfer and retrieval of critical care patients across Qatar.¹⁹ The program was further developed in 2016 and formalized under the Transfer and Retrieval division of the HMCAS, with dedicated HMCAS and CCN staff receiving bespoke training and continued education;¹⁸ the addition of specialized and dedicated communications staff for call taking, dispatch and monitoring; and focused governance and audit to maintain the highest quality of patient safety and quality of care.

Since then, the program has seen considerable success and uptake within the country's health system. The activity of the unit echoes much of what can be found in the literature and further reinforces the need for such a specialized service, regardless of setting (Table 1). It further highlights the importance of the relationship and cooperation between the HMCAS and CCN regarding the expertise and resources that each component adds to the overall service. This is particularly evident in the expectations of the team regarding their duties of care whilst in transit. A significant proportion of the patients transferred by the program have required the maintenance of a high-level of care between facilities, under conditions that are far more challenging than that seen in any regular hospital ward or intensive care unit (Table 2). Conclusion: In modern healthcare, to deliver a consistent and high-level critical care service in any setting, the movement of patients is inevitable. However, in order to ensure the continuum of this level of care and maintain the highest standards of patient safety and quality of care in-transit, specialized transfer services are a necessity. The multidisciplinary nature of critical care transfer and retrieval dictates the cooperation between multiple in-hospital and out of hospital specialties and is a fundamental underlying concept in the success of such services.

For the last three decades, efforts at improving the survival rate for patients post-cardiopulmonary arrest has remained unattainable. Confronting such challenge has opened the door to devise new strategies to improve patient outcomes at the onset of subtle deterioration, rather than at the point of cardiac arrest.¹ In 2006, the Institute for Healthcare Improvement (IHI) introduced the Rapid Response Team (RRT) concept, also known as the Medical Emergency Team (MET), as one of the six preventative steps needed to save the lives of patients who might otherwise die unnecessarily.² These six recommended interventions were included in a campaign by the IHI called the 100,000 Lives Campaign. A review of the literature was conducted to assess the certainty of clinical outcomes following the implementation of an RRT service within healthcare facilities. The main clinical outcome measures found included reduction of the:

– Incidence of cardiac arrests that occurred outside the intensive care unit (ICU), – Total ICU admissions, – Unplanned ICU admissions, and – Total hospital mortality rate per 1000 discharge.³

Despite the increasing utilization of RRTs worldwide, their effectiveness in reducing hospital mortality has been debated.⁴ However, the purpose of an RRT service is not to improve cardiac arrest management and outcomes. The primary focus of this concept is to identify patients before they deteriorate through improving patient monitoring on general wards (the afferent component) and improving the reliability of the response to deterioration by a dedicated Critical Care Outreach Team, Rapid Response Team, or Medical Emergency Team (the efferent component).⁴ The reliability of such systems depends on the faultless functioning of a “chain of survival” consisting of:

– Timely recording of vital signs, – Improved education and mindset of staff at the bedside to recognize pathological patterns, – Reporting of abnormalities to the efferent team, – Timely and appropriate response by the latter, – Repeating feedback loops.

Metrics to estimate failure rescue rates have been developed and are widely used as indicators of hospital quality. The Agency for Healthcare Research and Quality has developed a measure of failure to rescue intended to address concerns about variation in documentation among reporting institutions and the fact that other metrics of patient safety, such as mortality and complication rates, may be more a measure of patient-related factors than quality of care. Those metrics are limited to some degree in their usefulness because some patients with advanced illness simply do not want life-prolonging interventions, and some adverse occurrences are not preventable. Nevertheless, recognition of failure to rescue as a significant issue and an important quality indicator has prompted numerous studies of the underlying causes and the development of systematic approaches to address them. It is time to stop asking whether RRT “works.” Overall, the balance of evidence indicates that RRTs are effective at reducing cardiorespiratory arrest and mortality. The focus should now be more on how to improve detection of patient deterioration and promote a culture of safety.⁵

Sepsis is, in many patients, very difficult to recognise, especially early on and in the elderly and those with multiple comorbidities¹. This difficulty leads to delayed treatment in some, and over-treatment in others in whom bacterial infection does not exist. One large study of 2579 patients admitted to critical care for presumed sepsis showed that 13% had a post-hoc infection likelihood of “none” and an additional 30% of only “possible”². With increasing recognition of the many detrimental yet usually covert effects of antibiotics, such agents can only cause harm when given unnecessarily. There is a pressing need for reliable, early, sensitive, and specific biomarkers to (i) indicate the presence of infection, (ii) to indicate the likelihood that these infected patients will go on to develop organ dysfunction (sepsis), and (iii) to identify which specific treatments (e.g. immunomodulatory) should be administered to which patient in terms of timing, dosing, and duration.

Infection diagnostics have traditionally relied upon Gram stain and culture; the yield is low and often several days elapse before an organism is identified, speciated, and its antibiotic resistance pattern determined. Newer molecular diagnostics are arriving at an impressive pace and offer the opportunity for point-of-care testing at the bedside to identify micro-organisms (at least, the commonest pathogens), and some indication of antibiotic sensitivity, within minutes of sampling. Remarkably, bacteria within the lung can also be imaged in real time. As an example of the power of molecular diagnostics, one study involving 529 patients in nine European ICUs demonstrated that from 616 blood culture samples, polymerase chain reaction/electrospray ionization-mass spectrometry identified a pathogen in 228 cases (37%) whereas traditional blood cultures were positive in just 68 (11%)³.

For sepsis, current biomarkers such as C-reactive protein and procalcitonin are generally fairly sensitive but are too non-specific to accurately diagnose infection as the cause of inflammation, nor to identify which infected/inflamed patients will proceed to organ failure. Many patients will thus be unnecessarily treated with antibiotics while a smaller number may be inappropriately not treated. It is unlikely that a single biomarker will yield all the necessary information so technologies that can measure multiple markers will probably be more useful. Such devices are being developed, often for point-of-care testing, and include PCR (polymerase chain reaction), lateral flow, microfluidics, and nanotechnology^4,5. These promise to deliver results in 30-75 minutes at the bedside with no need for involvement of the main hospital laboratory. The challenge now is to find the best biomarkers.

Finally, for treatment selection, it has become clear that sepsis is an umbrella syndrome with many patient subsets within. Inflammatory and hyperinflammatory phenotypes have been described from a combination of clinical and biological markers. At least from retrospective studies, it appears that these subsets respond differently to fluid, PEEP (positive end-expiratory pressure), oxygen, and corticosteroids. So targeted treatment may become a reality in the not-too-distant future though prospective validation is first needed.

Shock is a state of ‘acute circulatory failure’, the key feature of which is an inability for tissues and cells to get enough oxygen to meet their needs, ultimately resulting in cell death¹. Shock can be classified as hypovolemic, cardiogenic, obstructive or distributive although many patients will have several types of shock simultaneously¹. Although it is important to identify and treat the underlying cause of shock (e.g., antibiotics and source removal for septic shock; thrombolysis or embolectomy for massive pulmonary embolism causing obstructive shock¹, hemodynamic support must be started immediately in all cases to provide a minimum perfusion pressure and prevent development or worsening of organ dysfunction. In this context, both “flow” and “pressure” are important components. Indeed, the arterial pressure is determined by blood flow and vascular tone, i.e., blood pressure = cardiac output x systemic vascular resistance. The essential aspects of shock resuscitation can be remembered using the simple VIP mnemonic: ventilate (ensure adequate oxygenation), infuse (provide adequate fluid resuscitation), and pump (administer vasoactive agents). Fluid administration should be guided by repeated fluid challenges so that patients receive enough fluid but not too much, as excess fluid can have multiple harmful effects. If hypotension is severe, vasopressors should be started early, at the same time as fluids, to increase systemic vascular resistance and thus arterial pressure. Prolonged periods of hypotension are associated with worse outcomes². Importantly, although an initial mean arterial pressure (MAP) target of 65 mmHg may be a useful aim, this will not be optimal for all and target values should be adapted according to the individual patient, taking into account various factors including age and history of chronic hypertension. Indeed, if the MAP target is too low, resultant hypoperfusion may lead to cellular death and organ dysfunction, but a target that is too high may be associated with edema and excessive vasoconstriction as a result of higher amounts of fluid and vasoactive agents³, which may also impair organ function. Patients with circulatory shock must therefore be carefully monitored, including regular assessment of cardiac output, and treatment and targets adapted accordingly. Monitoring organ perfusion at the bedside is difficult without specific tools to assess the microcirculation. As such, we must generally rely on three “windows” that can indicate inadequate perfusion, i.e., impaired cutaneous perfusion, impaired renal function, and impaired mental status¹. Plasma lactate levels can also be useful, with changes over time providing some indication of adequacy of tissue oxygenation. Although these changes are too slow to help acutely guide therapy, the trend can provide valuable information about patient status over time. If flow remains inadequate and there is no, or only a poor, response to fluids, an inotropic agent may be considered. Dobutamine is the inotrope of choice. In this context, measurement of mixed (SvO2) or central venous (ScvO2) oxygen saturation can help as it provides an indication of the balance between oxygen delivery and consumption, with low values ( < 70%) suggesting that increasing oxygen delivery could be beneficial⁴.

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is commenced for adult patients with severe acute cardiac failure refractory to conventional therapy or following protracted cardiac arrest refractory to cardiopulmonary resuscitation.¹ Following the commencement of ECMO there are several key questions which need to be addressed.

Initial investigations are those which are designed to understand the cause of the cardiac event, gain an understanding of the consequences of the event, particularly on other organ functions and also to direct initial treatment. At this stage, consideration should be given to basic biochemistry, electrocardiography, echocardiography, coronary angiography and computed tomography.² These investigations can explain the origin of the cardiogenic shock and direct therapy, for example stenting of culprit lesions or management of an autoimmune cardiomyopathy.

Additionally, clinical monitoring tools should be implemented to allow understanding of the consequences of the cardiac insult and the impact of ECMO. One of the key problems of peripheral VA ECMO is the increase in afterload for the native heart which prevents appropriate left ventricular emptying.³ An early understanding of left ventricular end diastolic pressure as well as left ventricular emptying can assist in planning the need for left ventricular unloading devices. Investigations including direct measurements of left ventricular pressure at the time of the coronary angiogram can give a static measure of the impact of afterload. Continuous monitoring using pulmonary artery catheterisation with measurement of pulmonary capillary wedge pressure as well as intermittent echocardiography can help identify rises in left ventricular end diastolic pressure which may result in serious complications including pulmonary oedema, pulmonary haemorrhage, left ventricular distension and left ventricular thrombosis.

Investigations or clinical monitoring is also essential to facilitate optimal patient management. Early in the course of VA ECMO, there are naturally concerns about the ability of the ventricle to empty, however during cardiac recovery there is also the potential for the heart to eject deoxygenated blood, particularly if the lungs are yet to recover. Monitoring including continuous peripheral saturation monitors, arterial blood gases and cerebral near-infrared spectroscopy can all assist in understanding the relative provision of blood to the brain from ECMO or the native circulations.⁴ Similarly, continuous investigations of the blood supply distal to the cannulated peripheral artery are essential. There is a substantial risk of femoral arterial thrombosis and this can be managed through the use of intermittent doppler signals for the distal vessels or through the use of near-infrared spectroscopy for the legs.⁴

Finally, there is a requirement for monitoring and investigation of the pump and its function/impact on the patient. This includes identification of complications such as haemolysis, microthrombosis, air embolism and disseminated intravascular coagulopathy.⁵ Circuit gases can also be used to demonstrate functioning of the circuit and to prevent exposure of organs to profound hyperoxia or non-physiological pH.

In conclusion, there are a number of key investigations and clinical monitoring devices which should be undertaken following the commencement of VA ECMO to both understand the cause and to predict/prevent complications.

Critically-ill patients may have their abdomens opened as a result of primary pathology (damage-control laparotomy in trauma, soiled peritoneum from perforated hollow viscus, necrotizing pancreatitis), or as treatment for abdominal compartment syndrome (defined as new organ dysfunction associated with intra-abdominal hypertension).

The incidence and implications of intra-abdominal hypertension and abdominal compartment syndrome (ACS) in particular, are currently debated.

Intra-abdominal hypertension (IAH) is defined as a sustained intra-abdominal pressure ≥ 12 mmHg. Grading is possible; Grade I = IAP 12 to 15 mmHg, Grade II = IAP 16 to 20 mmHg, Grade III = IAP 21 to 25 mmHg, Grade IV = IAP >25 mmHg. Management principles include reduction of intra-abdominal gas (NGT and flatus) and intra-abdominal fluid (the latter may be interstitial or intra-peritoneal), and ensuring the abdominal wall is as compliant as possible. Definitive management is to open the abdomen however, the benefits and use of the open abdomen (OA) approach are unclear. The rates of OA appear to be reducing worldwide.

The reduction in the incidence of ACS requiring laparostomy may be related to global changes in resuscitation targets¹, rather than changes in surgical techniques. In particular, the notion of ‘fluid de-resuscitation’ may be implicated in improved outcomes.

The decision to leave the abdomen open after emergent laparotomy seems to be dependent on the surgical specialty of the operating surgeon, and is a common approach applied in victims of blunt abdominal trauma².

Complications of the open abdomen relate mainly to nutritional status and long-term abdominal complications. The most feared abdominal complication relates to the inability to close the abdominal fascia, with associated increases in mortality, fistula formation, and ventral hernias.

Current critical care focus is on the prevention of the open abdomen. For intra-abdominal hypertension and acute compartment syndrome, medical management aimed at reduction of abdominal wall pressure and evacuation of intra-abdominal contents (including fluid) are cornerstone strategies. The use of neuromuscular blocking agents is controversial; short-term benefit may be outweighed by long-term complications.

For the de novo open abdomen, current research suggests a possible role for more aggressive early closure (primary or before day 5, latest day 8). Further research is required to confirm whether primary closure is safe. Temporary closure techniques using a combination of negative abdominal wall pressure in combination with partial mesh reduction seems to be helpful in increasing successful abdominal closure rates³.

Aggressive infection control and nutritional support after 72 hours is key. Common to both scenarios is the need for careful, judicious fluid management; organ perfusion must be optimized, but not at the expense of massive bowel and abdominal wall edema. The latter complicates healing and closure⁴.

A final question is whether extubating patients with an open abdomen is safe and feasible. The literature provides a resounding yes to this issue⁵.

The shortage of organs for transplantation is a serious medical problem. More than 90% of organ donors are patients who die after the irreversible cessation of all brain function in Intensive Care Units (ICUs) but 5–10% of these patients who fulfill the criteria of brain death suffer cardiac arrest before becoming an organ donor therefore their organs can no longer be utilized¹.

Reasons why a potential donor does not become a utilized donor includes failure to identify/refer a potential donor, hemodynamic instability/unanticipated, and cardiac arrest with consecutive organ damage amongst others. Because the majority of potential organ donors are in the ICU, the critical care management guided by the intensivist plays a key role. The intensivist's responsibilities include the timely identification and referral of the potential organ donor for Donation after Brain Death (DBD) and Donation after Circulatory Death (DCD), optimization of the brain-dead donor by early goal-directed management of the physiological consequence of brain death, in addition to development and implementation of protocols and clinical pathways for DCD in collaboration with the organ transplant team in the hospital². Identification and referral should be done as early as possible and should be guided by best available evidence guidelines e.g. the NICE Clinical Guidelines “Organ Donation for transplantation”. If not yet addressed, the organ donation team will approach the family to obtain their consent for organ donation.

The clinical picture of physiological changes that follow brain death is not uniform. Severity and occurrence of dysfunctions are related to the etiology and time course of brain death. Most common are hypotension, diabetes insipidus, hypothermia, and plasma electrolyte imbalance in comparison to pulmonary edema, metabolic acidosis, cardiac arrhythmias, and disseminated intravascular coagulation³. The general management principles in the ICU regarding DBD and DCD are similar. The donor management goals shall ensure physiological homeostasis to maintain the best possible organ function at the time of organ harvesting and includes cardiovascular, respiratory, fluid, electrolyte, hormone, blood, coagulation and temperature management to maintain normovolemia, hemodynamic stability, and normothermia⁴. A recent prospective study investigated the effect of the implementation of a Donor Management Goals (DMG) bundle that focused on maintaining parameters like blood pressure, central venous pressure, ejection fraction, arterial blood gas, PaO2/FiO2 ratio, sodium, blood glucose with support of low dose vasopressors within normal limits. The achievement of any 7 of 9 DMGs was associated with a substantial increase in the number of organs available for transplantation⁵. Meanwhile, many countries recognized that the principle of organ donation should be a routine component of end-of-life (EOL) care.

By implementing strategies of early identification and evidence-based goal-directed management protocols to preserve organ function, the critical care team guided by an experienced intensivist in collaboration with the organ donation team can help to improve organ availability and quality to overcome shortage of organs for transplantation.

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

Weaning is the process of successfully liberating the patient from mechanical ventilation. The majority of patients will separate from the ventilator after a successful spontaneous breathing trial (SBT).¹ In a minority of patients, weaning can be challenging and prolonged. Finding the cause of weaning difficulty is crucial to minimize the rates of extubation failure and prolonged ventilation.

Diaphragm dysfunction (DD) has been described as a separate entity responsible for weaning failure with an incidence of 23–80%. It has also been associated with difficult weaning, prolonged intensive care unit (ICU) stay and mechanical ventilation, and increased ICU and hospital mortality.² Sepsis, shock, and ventilator induced diaphragm dysfunction are important risk factors of DD. Diaphragm dysfunction has several mechanisms. Disuse atrophy and microstructural changes of the diaphragm have been described as the two cardinal pathophysiologic features.

Establishing the diagnosis of DD can be complex in critically ill patients. Bilateral anterior magnetic phrenic stimulation is widely considered as the gold standard but is only available in large research centers with limited availability. Ultrasonography of the diaphragm is a promising tool given its wide availability, affordability, and non-invasive nature. Ultrasound is operator dependent, however and it does not provide continuous monitoring capabilities. The diaphragm thickening fraction (DTF) can be calculated from measuring the end-expiratory and end-inspiratory diaphragm thickness at the bedside. It correlates well with transdiaphragmatic pressure.³ Electromyography of the diaphragm may overcome the limitation of ultrasound by offering a continuous assessment of the diaphragmatic electrical activity, but it requires the placement of a specialized nasogastric tube.

Management of DD is better approached by implementing a preventive and a curative strategy. From animal studies, allowing for spontaneous breathing on mechanical ventilation may prevent the problem. The degree of the recommended patient effort and ventilator assistance to achieve optimal balance between diaphragmatic loading and unloading are yet to be defined. Monitoring DTF while finding the optimal ventilator support level can be useful in this context. Another modality to prevent DD is diaphragm pacing applied through a transvenous phrenic nerve pacing system. Animal studies in pigs showed that this modality resulted in less diaphragm atrophy when pacing was synchronized with ventilation.⁴ There is an ongoing study to assess the role of diaphragm pacing to recondition and strengthen the diaphragm in difficult to wean mechanically ventilated patients (Clinicaltrials.gov NCT03107949).

Once diaphragm dysfunction is established, no specific treatments exist at this time. Other causes of weaning failure like cardiac dysfunction have to be excluded and treated. Improving respiratory load and respiratory muscle weakness imbalance is also crucial. While it appears to improve inspiratory muscle strength parameters, inspiratory muscle training has not consistently shown improvements in weaning success.⁵ Levosemindan showed some benefit in improving diaphragm contractility and efficiency in healthy volunteers but was later found to increase likelihood of weaning failure in septic patients. Anabolic steroids were not found to be effective in treating diaphragm dysfunction in several studies. More evidence is needed before recommending non-invasive ventilation post-extubation in all DD patients.

Intermediate (“submassive”) pulmonary embolism (PE) is proven acute PE without shock but with elevated troponin, BNP, or NT-proBNP, with either contrast-enhanced chest CT or echocardiographic evidence for right ventricular (RV) dysfunction, usually enlargement. However, definitions of intermediate PE vary widely: Some allow a single abnormality of any of the five (two imaging; three biomarker) results, and some would accept normal findings in all five but ECG evidence of RV strain. The quite varied criteria means recommendations for intermediate PE management frequently are not derived from the same type of patient. Diagnosis: Intermediate PE is considered after a diagnostic CT PA-gram with filling defects. The imaging study RV:LV cavity dimensions can be measured in the same image, but a ratio >1.0 is not predictive for adverse outcomes. Abnormal interventricular septum position and reflux of IV contrast into the IVC are associated with poorer outcomes. Echocardiography can measure RV and LV cavity dimensions in the 4-chamber view, but measurements without echo contrast are unreliable. Dynamic views of the RV can show impaired contraction, and/or reduced tricuspid annular plane systolic excursion (TAPSE), and/or elevated estimated pulmonary artery systolic pressure. But in a recent study by expert investigators, 27/83 (33%) of patients presenting to the Emergency Department with persistent dyspnea but CT PA-grams negative for PE had RV dysfunction by one or more of these echocardiogram criteria¹. “RV dysfunction” is prevalent in dyspneic patients; in the acute PE patient, it may not be related to the PE. Thrombolysis: A randomized trial of weight-based IV tenecteplase vs placebo² added to heparin compared outcomes in 500 patients in each group with intermediate PE, defined as requiring CT or echocardiographic RV dysfunction and elevated troponin. At day 30 tenecteplase deaths were 12 vs 16, respectively (p = 0.42) but significantly more strokes (12; 10 hemorrhagic, incidence 2.4%) vs 1 (incidence 0.2%) (p = 0.003), and extracranial bleeds occurred in 32 (6.3%) tenecteplase patients vs 6 (1.2%), (p < 0.001). Chronic thromboembolic pulmonary hypertension (CTEPH) was 2.6% in both groups after 3 years. An accompanying editorial³ concluded: No routine systemic thrombolysis; instead, observe for deterioration, for example, shock. To reduce bleeding, catheter-directed thrombolysis (CDT) for intermediate PE (mostly case series, sometimes ultrasound-enabled catheters; up to 20 mg rt-PA) has been reported. In the only randomized study (30 patients/group), ULTIMA⁴, 90-day mortality (0 vs 1), RV/LV ratio, and TAPSE were the same as with anticoagulation. 24-hour pulmonary artery pressure results were superior with CDT. Recommendations: In intermediate PE, observe carefully. Bolus IV heparin 80 U/kg actual body weight during the diagnostic work-up, infuse 18 U/kg actual body weight if the PE diagnosis is proven or likely. Obtain baseline BNP or NT-proBNP and follow every 6–12 h to help assessment. If hypotension occurs, consider half- or full-dose rt-PA⁵. If systemic thrombolysis is contraindicated, try catheter-directed thrombolysis by mechanical fragmentation or with 10–20 mg rt-PA infusion into the most important clot.

When active bleeding, impaired hemostasis, and high bleeding risk are concerns, give IV heparin without a bolus, 200–300 U/hour, and observe 6–8 h for hemostasis. Increase by 100 U every 8 h if tolerated without excessive bleeding until 600–800 U/h, then continue until bleeding risk remits. Consider a retrievable IVC filter.

In a busy and hectic critical care setting, sometimes an ‘emergency’ Do Not Attempt Resuscitation (DNAR) conversation has to take place to prevent unnecessary ‘futile care’. Traditionally, this is the responsibility of Intensive Care Unit (ICU) doctors after discussion with family members, or by the primary care doctors after discussion with patients themselves prior to them becoming critically ill. Many critically ill patients with known ‘terminal illnesses’ brought to the Emergency Department (ED) in Qatar do not have a DNAR order. Increasingly, DNAR conversation is being undertaken by Emergency Physicians (EP), alongside ICU doctors. Often, these difficult conversations with family members occur in the ED prior to escalating resuscitation, if time permits. In Qatar, three physicians need to sign the DNAR order if they think it is clinically appropriate. Patients or their family members do not need to sign. However, hospital regulation allows it only after discussion with and agreement from them. Often, the DNAR order also includes the maximum intervention agreed. Some family members object the DNAR order, and insist on ‘full resuscitation’ and organ support, despite explanation of the poor prognosis, and the likelihood of non-curable deterioration. This review looks at the current practice, challenges and evolution of ‘emergency’ DNAR conversation in critically ill adult patients in Qatar.

There are at least two different ‘opposing’ approaches to DNAR discussion with patients (and more often the case with family members of patients in critical care setting). The most often used is the patients’ choice approach¹. In some society, patients discuss openly with their doctors about their condition fairly early on in the course of their illness. When they become critically ill, a similar discussion is undertaken with family members (or surrogates). A lot of emphasis is put on personal choices and preferences. Another approach, is a physician's driven DNAR recommendation when the clinical circumstance is appropriate². This happens more commonly when patients present to hospital in late stages of their terminal illness (or with acute deterioration) without any DNAR order. In certain societies, DNAR is not generally discussed unless the condition is acute, life-threatening and the likelihood of a meaningful recovery becomes extremely small.

Both approaches are probably the two ends of the same spectrum (see Diagram 1). Both involve risk-benefit discussion (and likelihood of success with good outcome) of cardiopulmonary resuscitation (CPR) in the event of deterioration and cardiac arrest. Having agreed on a DNAR status does not mean that the patient will get substandard care. Patients and families have to be reassured of this fact. Given the appropriate care, many patients with DNAR status recover from their acute illness episodes and are successfully discharged home after emergency hospitalization³. An appropriate DNAR order will guide the medical team (doctors and nurses) to avoid unnecessary ‘futile care’, and hopefully lead to ‘better’ personalized care for patients and their families⁴.

Intensive Care Unit (ICU) support is provided with the aim of maintaining the vital functions, reducing mortality and morbidity in patients with a severe critical illness.¹ Despite having newly developed technologies and improvement in care, the death rate in the intensive care unit remains high, ranging between 20-35%.¹ The care that people receive at the end of their lives has a profound impact not only upon them but also upon their families and carers.

End of life (EOL) in the ICU is a challenge. Nature and spirituality have been superseded by all that medical science has to offer by way of technology and life support, prolonging the dying process and dictating the time of death.²

Death as it occurs in the ICU is neither simple nor natural. Caring for dying patients and their families is thought to be most stressful and painful to the nurses who constantly attend to the patients whereas other healthcare providers can visit and then walk away.³ There are only limited studies from the perspective of critical care nurses on obstacles and/or supportive behaviors that either restrict or promote good care for dying patients even though there are adequate documentation of the difficulties and inadequacies of providing EOL care to patients.³

It is well identified that the nurses have a decision making role as they act as a link between families and physicians in decisions at the end of life while interpreting and explaining information.²

It has been noted that the nursing paradigm of enhancing communication, reducing symptom burden, and supporting families are aligned with the common domains of EOL care.⁴ The study using the grounded theory approach to formulate a conceptual framework of the nursing role in EOL decision making in an ICU setting concluded that the core concept, supporting the journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses describe being present with patients and families to validate feelings and give emotional support, nursing work, while bridging the journey between life and death, imparting strength and resilience and helping overcome barriers to ensure that patients receive holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.² Thus involving the nurses in the multidisciplinary decision making of EOL care will be beneficial.

Nurses play a very important role in EOL care by providing family care and collaborating with the rest of the medical team.⁵ Working as a nurse within the wider ICU team requires good collaborative and communication skills and few studies have focused on how we foster these skills to enhance EOL care in the ICU. Little is known about the role of nurses in end of life in the critical care setting, and therefore a grounded theory study in this area is needed to further understand this important role.²

Pediatric sepsis comprises a spectrum of disorders that result from infection by bacteria, viruses, fungi, or parasites. Sepsis ranges from bacteremia, with early signs of circulatory compromise to complete collapse with multiple organ dysfunction and death. Early recognition improves outcomes for infants and children. Over the past two decades, sepsis has been defined and redefined with modifications for the pediatric population. The most recent iteration, complementing the NICE guideline (NG51) “Sepsis: Recognition, diagnosis and early management”, was published in 2017.¹

Pediatric severe sepsis usually is community-acquired (57%) with the respiratory tract as the primary site of infection. Mortality rates associated with sepsis and septic shock in patients admitted to the pediatric intensive care unit are 5.6% and 17.0%, respectively.²

The SIRS adult criteria have been modified to produce pediatric-specific definitions. Per the 2017 Sepsis-3 guidelines, sepsis in adults is no longer based on the SIRS criteria, rather it is defined as an infection with at least one organ dysfunction. Although it may change in the future, the definition for the pediatric population remains based on the SIRS criteria due to weak evidence.^3,4 Although not included in the definition of sepsis, hyperglycemia, altered mental status, and high lactate, are highly suggestive of sepsis and should be considered when evaluating a patient.

Risk factors for pediatric sepsis include less than one month of age, serious injury, chronic medical problems, immunosuppression, indwelling devices, and urinary tract abnormalities. Sepsis should be in the differential diagnosis in children with persistently abnormal vital signs such as tachycardia that is often missed and attributed to other causes. Hypotension is a late finding in children; the diagnosis of shock cannot be based solely on this finding. Unlike adults, previously healthy children can compensate extremely well during hypoperfusion states and do so for relatively long periods resulting in sudden decompensation.²

Timely response to sepsis is vital to survival. Vascular access needs to be obtained, fluids administered (minimum of 60 ml/kg), broad spectrum antibiotic coverage and initiation of inotropic support in fluid refractory shock need to occur within the first hour. Hydrocortisone should be considered with catecholamine-resistant shock and if at risk for absolute adrenal insufficiency. Laboratory diagnostics such as white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) are often nonspecific. More novel tests such as lactate and procacitonin are more specific clinical adjuncts that will support diagnosis, monitor, and trend a child's progress.^1,5

Key recommendations of the 2017 guidelines highlighted the importance of bundles: “recognition bundle” with trigger tools for rapid identification; “resuscitation and stabilization bundle” to increase adherence with best practice principles; and a “performance bundle” to identify gaps and barriers in the system.¹

Not every child with fever will have a serious infection leading to sepsis. Delays in recognition and management will worsen the prognosis significantly; early recognition is crucial. Any child with a suspected infection, persistently abnormal vital signs, or a concerning exam after antipyretics and intravenous fluids should be investigated and treated for sepsis. Rapidly changing standard of care makes sepsis a critical diagnosis for clinicians.

Pediatric acute respiratory distress syndrome (PARDS) incidence is reported between 2.95 to 12.8 cases per 100,000 person years,^1,2 which is lower than in adults but remains one of the most challenging form of lung diseases for a Pediatric Intensivist. Application of the adult ARDS definition is limited in pediatrics due to differences in risk factors, etiology, pathophysiology, hard to obtain PaO2 values, and lower levels and variation of PEEP utilization. To address these limitations, to promote early recognition and diagnosis of PARDS, and to improve prognostication and stratification of disease severity, the Pediatric Acute Lung Injury Consensus Conference (PALICC) published the first definition for PARDS in 2015.³

This definition (Table 1) kept the criteria of onset within seven days of a known clinical insult and the presence of respiratory failure not fully explained by cardiac failure or fluid overload. It eliminated the term acute lung injury, excluded bilateral infiltrate, and stratified severity of PARDS based on the oxygenation deficit as mild, moderate, and severe. Either oxygenation index or the oxygen saturation index (when arterial blood gas is not available) can be used to assess the degree of hypoxemia. Non-invasive ventilation is now included for continuous positive airway pressure of more than 5 cm H2O. Furthermore, PALICC included recommendations for defining PARDS in children with preexisting chronic lung disease, cyanotic congenital heart disease, and left ventricular dysfunction.

The PARDS management guidelines are based on very limited pediatric data and are largely based on expert opinions.³ For ventilatory management, no mode of ventilation is found to be superior, patient-specific tidal volumes per ideal body weight according to disease severity are recommended (3–6 mL/kg for patients with reduced and 5–8 mL/kg for patients with better-preserved compliance). In the absence of transpulmonary pressure measurements, plateau pressure should be limited to 28 cm H2O and 29–32 cm H2O during increased chest wall elastance. Moderately elevated PEEP to 10–15 cm H2O should be titrated in severe PARDS to the observed oxygenation and hemodynamic response. The oxygenation goal for mild PARDS (PEEP < 10) is 92–97% and severe PARDS (PEEP >10) 88–92%, although in some patients, < 88% can be considered with oxygen delivery monitoring. Permissive hypercapnia with a pH of >7.15 is the goal except in severe pulmonary hypertension, intracranial hypertension, select congenital heart lesions, significant ventricular dysfunction with hemodynamic instability, and pregnancy. Recruitment maneuvers by slow incremental and decremental PEEP steps may be used for severe hypoxemia. High-frequency oscillatory ventilation remains as an alternative ventilatory mode for patients with moderate-to-severe PARDS. There is not enough evidence to support the routine use of inhaled nitric oxide, steroids, or prone positioning for PARDS at this time.³

Since the publication of the new definition, several studies comparing the previous definitions to PALICC suggest that the PALICC definition can not only identify more patients with PARDS but it is also better at risk stratification for mortality.^4,5 Despite decades of research and experience of managing PARDS, there remains a lack of definitive clinical evidence in Pediatrics. Further pediatric research is needed to gain more insight and to improve outcome of PARDS.

One of the main reasons for children needing hospital admission is the need for respiratory support and monitoring. Intubation and ventilation has been the standard method of supporting patients in respiratory failure. With better ventilators and interfaces many of these children with respiratory failure could benefit from non-invasive ventilation (NIV). The main advantages of NIV over its invasive counterpart are reduced need for sedation, avoiding laryngeal and tracheal injuries, reducing nosocomial infections, and shorter length of stay.^1,2

NIV can be used for acute conditions. Studies have shown that NIV is more successful in type 2 respiratory failure compared to type 1 respiratory failure as in type 2 respiratory failure, a failing pump is replaced by another pump i.e., NIV machine.^3,4

With improvement in technology NIV has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. Use of NIV has not spread worldwide. Even in the countries where they are being used, there is huge variability in the use of NIV. This reluctance in usage could be partly explained by the lack of adequate scientific literature in children concerning this technology.

The first thing to do to overcome this barrier is to create an understanding and familiarity of this technology, resulting in more usage of NIV which has been shown to improve the quality of care and reduce cost of healthcare.

A FAST-NIVT (Forwarding Advanced Simulation Training in Noninvasive Ventilation Therapy) project supported by the Respiratory group of ESPNIC (European Society of Pediatric and Neonatal Intensive Care) has developed blended courses (online and face to face) for attendees and for NIV trainers in order to promote the teaching and learning of NIV around the world.

As an extension of this project we have developed a structured algorithm with the acronym ICEMAN (Figure 1) and used it to train our clinicians in the judicious selection of patients, contraindications and equipment used for NIV.² This approach helps the teams to recognize failure of non-invasive ventilation, troubleshoot hypercapnia and hypoxemia, manage asynchrony and plan for weaning or escalation of care using algorithms.

We have conducted workshops globally to provide clinicians with best practice recommendations and guidance about how to best deliver non-invasive ventilation to patients who sometimes need this lifesaving technology. By attending this workshop, delegates would be able to understand the various indications, NIV options, modes of delivery, effective monitoring, and analysing failures which will definitely go a long way in providing this care more effectively with less failure.

All the workshops are led by trained educators who are experienced practicing paediatric intensivists, neonatologists, and pulmonologists with an extensive NIV experience. To make learning fun and to encourage participation, high-quality learning materials and skill stations have been tailored to the needs of each group. This methodology has been successfully used to train the next generation of clinical champions.