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

Background: Cannulation, in extracorporeal membrane oxygenation (ECMO), is the act of inserting a cannula through the body¹. For femoral veins, femoral arteries, and the jugular vein, the cannula stops at the inferior vena cava (IVC) beside the hepatic vein and at the beginning of the distal aorta, and the superior vena cava at the right atrium, respectively. Cannulation is considered a critical operation and requires intensive training. Simulation-based training (SBT) is the gold standard, allowing for training in risk-free, versatile, and realistic environments². A research collaboration was established between Hamad Medical Corporation and Qatar University College of Engineering to support the development of the ECMO training programme. Initially an ECMO machine simulator was developed with thermochromic ink to simulate blood and modules that simulate common emergencies practitioners may face during ECMO runs³. This cannulation simulator is now being designed to close the gap in the market in relation to cost and fidelity^4,5. Methods: The cannulation simulator is composed of several modules. Firstly, a 3D-printed femoral pad mold was constructed to facilitate the production of cannulation pads (Figure 1(a), (c)). Secondly, cannulation pads were designed so they are anatomically correct and ultrasound compatible. For the arteries, the superficial artery was added at the access point to simulate possible incorrect routes for the cannula. Furthermore, the orientation of the veins and arteries were set to further resemble the human anatomy, where the arteries are situated above the veins (Figure 1(a), (b)). In addition to the implementation of a closed loop linking the jugular to the femoral, cannulation access points with a pump connected to a tank between them to regulate the flow. The blood flow in the arteries was enhanced with a pump to simulate a pulsatile flow while the flow in the veins is laminar as seen in the single loop implementation (Figure 1(h)). The connection of the pump to the embedded system is shown in Figure 1(g). The junctional point in the IVC was designed in the venous loop to allow for two cannulas to pass and an alternative path simulating the renal vein was added. A force sensing resistor (FSR) was connected to detect and measure incorrect entry of the guide-wire as this, in real-time scenarios, could cause internal bleeding to the patient (Figure 1(g)). Lastly, the Y-connector showing the renal vein entry is shown in Figure 1(d) and (e). Results: Tests were done on the system namely on the FSR to recalibrate it in the presence of liquid. Tests on the pulsatile flow were conducted to optimize for realism in terms of pressure. Since both jugular and femoral cannulation access points are included, the simulator can be used for training for all ECMO modes including veno-arterial and veno-venous. After testing, the main limitations of the current prototype include the flexibility of the tubes, limits on FSR measurements, and the rigidity of the available 3D printing material. Conclusion: After implementing the stated features, the anticipated outcome is a realistic and cost-efficient ECMO cannulation simulator.

Background and Objective: Delirium in critically ill patients is common and distressing.¹ The incidence of delirium in intensive care units (ICU) has been reported to range from 45-87%.^2,3 Arguably, delirium is a well-recognized cause of morbidity and mortality among ICU patients. It can lead to longer hospital stays, lower six-month survival, and cognitive impairment persisting even years after discharge.³ It has therefore been recommended that all ICU patients are assessed for delirium using a validated tool.³ To date, limited data is available on the prevalence of delirium in surgical patients. In a study published in 2008, the observed risk was 73% in surgical and trauma patients.⁴

This study aimed to evaluate the incidence and modifiable risk factors of delirium in the surgical intensive care unit (SICU) of a tertiary care hospital in a developing country. Methods: We conducted a prospective observational study in patients over 18 years of age who were admitted to the SICU for more than 24 hours in Aga Khan University Hospital, Pakistan, from January 2016 to December 2016. The SICU has 9 beds and is run by trained intensivists with 24/7 coverage. Nurse to bed ratio is 1:1. Admissions are received from the emergency department, operating room, and surgical wards. After approval from the University's ethical review committee, written informed consent was taken from the patient's next of kin. Patients who had a preexisting cognitive dysfunction, signed a Do-Not-Resuscitate order, or stayed in the SICU for less than 24 hours were excluded from the study. Delirium was assessed by the Intensive Care Delirium Screening Checklist (ICDSC).⁵ The incidence of delirium was computed and univariate and multivariable analyses were performed to observe the relationship between outcome and associated factors.

Results: The average patient age was 43.29 ± 17.38 years and BMI was 26.25 ± 3.57 kg/m² (Table 1). Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. In univariate analysis, chronic obstructive pulmonary disease (COPD), fever, pain score >4/10, agitation, sedation, hypernatremia, length of ICU stay ≥ 7 days, and mortality were significantly higher in patients who developed delirium (Table 2). Patients on midazolam and propofol were four times more likely to develop delirium. Patients on pethedine were also more likely to develop delirium. Multivariable analysis showed that COPD, pain score >4, and hypernatremia were strong predictors of delirium (Table 3). Midazolam [aOR = 7.37; 95% CI: 2.04-26.61] and propofol exposure [aOR = 7.02; 95% CI: 1.92-25.76] were the strongest independent delirium predictors while analgesic exposures was not statistically significant to predict delirium on multivariable analysis. Conclusion: Delirium assessment is taken seriously and has been done for a long period of time in our unit. Our lower indicence rate of delirium concerns only the surgical patient population and reflects different assessment modalities used as well as pharmacological and non-pharmacological therapeutic options in comparison to the traditional approaches. In addition, we use different strategies such as bundles, sedation and pain protocol, and appropriate family interactions with the patients to minimize delirium. Delirium is a significant risk factor of poor outcome in SICU. This study showed an independent association between inadequate pain control, sedative medication, COPD, hypernatremia, and fever in developing delirium.

Background and Aim: Bronchiolitis is an acute viral lower respiratory tract infection. It is a common disease among children below 2 years old, resulting in frequent presentation to the emergency department and occasionally admission¹. For proper management of such patients, studying the disease spectrum and the risk factors is important². The aim of this study was to investigate the demographics and risk factors for severe bronchiolitis in children (0–2 years old), in the emergency department (ED) at Sultan Qaboos University Hospital (SQUH). Methods: We conducted a retrospective cohort study, including children ( < 2 years old), who came to the ED with a presentation suggestive of bronchiolitis. We reviewed the charts for a two-year period (January 2015–December 2016). Demographic and baseline characteristics were gathered from electronic medical records and then analyzed. We categorized patients into severe and non-severe bronchiolitis according to the guidelines set by the New South Wales (NSW) Ministry of Health in Australia in 2012 for the “Acute Management of Bronchiolitis in Infants and Children”³. Therefore, in our study children who were considered to have severe bronchiolitis had one of the following: unwell appearance, apneas, severe tachypnea (>70 breaths/min), bradypnea ( < 30 breaths/min), moderate to severe grunting, cyanosis, pallor, oxygen saturation < 90% in air (or < 92% in O2), tachycardia (>180 beats/min) and difficulty in feeding (taking less than 50% of normal feed).

We investigated the following risk factors to predict severe bronchiolitis: maternal age, birth weight, prematurity ( < 37 weeks of gestational age), age < 12 weeks, congenital heart defects, congenital respiratory diseases, immunodeficiency, and global developmental delay. We described the cohort using descriptive statistics and performed a logistic regression analysis to determine the risk factors for severe bronchiolitis. Results: Of the 235 children with bronchiolitis, 133 had severe bronchiolitis while 102 had the non-severe form of the disease, with a greater percentage of males than females in both groups. The majority of children with severe bronchiolitis were in the age < 3 months group (32%), while the least was in the ≥ 12 months age group (10%). There was a trend toward statistically significant results for the following factors: chronological age < 12 weeks (OR = 2.67, 95% CI = 0.89–2.67), congenital cardiac diseases (OR = 2.12, 95% CI = 0.85–5.30) and congenital respiratory diseases (OR = 1.86, 95% CI = 0.80–4.27).

The following factors were associated with severe bronchiolitis using stepwise logistic regression: increased heart rate (OR = 1.046, 95% CI = 1.026 – 1.066), decreased SpO2 (OR = 0.890, 95% CI = 0.827 - 0.957), male gender (OR = 2.248, 95% CI = 1.105 – 4.573), irritability (OR = 2.209, 95% CI = 1.024 – 4.769) and global developmental delay (OR = 3.5, 95% CI = 1.0 – 12.537). Conclusion: Multiple factors were associated with severe bronchiolitis and three were trending toward significant association including the younger age group, presence of congenital heart and respiratory diseases⁴. Low saturation, tachycardia and irritability were both part of the diagnostic criteria for severity and risk factors which confirms the clinical importance of these factors. Further investigations with a prospective study and a bigger sample size are required to confirm our findings and find other associated factors.

Background: Reflective practice has become an integral element in healthcare and education.^1,2 Hamad Medical Corporation (HMC) is the largest healthcare organization in Qatar and it aims to: develop highly competent healthcare practitioners, promote nurses’ critical thinking, enhance the implementation of evidence-based practice, encourage deep learning approaches, create positive learning environments, maintain patient safety, and bridge the gap between theory and practice in the critical care clinical settings.³ To achieve this, in 2015, reflective learning conversations and debriefing educational methods have been introduced by the HMC Nursing Education and Research Department. Methods: The HMC critical care education team introduced a new one-hour Continuing Professional Development (CPD) educational activity under the title of “Reflective learning conversation and debriefing”. This educational activity has been officially added to the critical care monthly and annual education plans and calendars. The reflective and debriefing discussion aims to give the chance for the critical care practitioners to share their real clinical experiences.^1,2,4,5 The critical care nurses of HMC attend each session in a group of 5-7 clinicians and they are asked to reflect critically on a real clinical cases in relation to challenges, limitations, pitfalls, and improvement plan.^2,5 A facilitator with a clinical and educational background facilitates the discussion and nurses are encouraged to summarize the learning lessons from that experience in addition to the recommendations and action plans which will be decided accordingly. This is then disseminated and shared with other healthcare facilities if it fits their scope of service. The reflective learning conversation and debriefing guidelines and protocol were established by the corporate nursing education team and are available to clinicians and facilitators (Table 1). Results: Reflective learning conversation with a debriefing improves nurses and health care practitioner's critical thinking and competency level which was evident by learners’ feedback and clinical competency assessment (Table 2). Furthermore, that educational activity is an attractive teaching and learning method to create dynamic learning environments in the critical care clinical settings which was evident by learners and facilitators’ feedback (Table 2). Moreover, nurse empowerment and active engagement were enhanced and encouraged by applying that educational method which was evidenced by the clinical experts’ feedback (Table 2). Finally, applying that method was effective to enhance evidence-based practice and patient safety in critical care settings (Table 3). Conclusion: Reflective learning conversations and debriefing has been perceived to be an effective learning method. Healthcare practitioners can learn from errors and previous experiences to avoid future mistakes in clinical practice. Sharing clinical experiences provides a medium to discuss cases from different angles and in depth which helps to promote deep learning, evidence-based practice, active learning, and patient safety. The recommendations of reflective learning conversations and debriefings can be applied and utilized to change current practice toward best practice and are applicable in all clinical domains and specialties. Although currently attended only by nurses, such sessions would be even more beneficial if attended by multiple professions.

Background: Sepsis and septic shock are medical emergencies and necessitate early and timely recognition and intervention. Failure of early recognition can lead to significant deterioration and may unfortunately culminate in death.^1,2 Young people are considered at high risk of sepsis.^3,4

Despite hundreds of trials and a multitude of approaches, an effective and efficient sepsis-cure agent does not exist. Most research into sepsis management has ended with non-conclusive and sometimes confusing results. Current evidence recommends a bundle of simple interventions to be accomplished as soon as possible and preferably within the first hour of sepsis recognition.^2,5

A number of international initiatives aim at reducing sepsis mortality.² Recently the World Health Organization (WHO) urged governments to set national mechanisms to tackle sepsis. A nation-wide sepsis program was developed to improve sepsis care for people in Qatar. A parallel National Paediatric Sepsis Program was developed to provide appropriate guidelines, education, a unified national care pathway, and to increase awareness of paediatric sepsis. Here we discuss the design and outcome of the Qatar paediatric sepsis program to date.

Methods: The program aims for early sepsis recognition and 95% compliance with the Sepsis Care Bundle by the end of 2019. To achieve this target a multi-faceted approach to paediatric sepsis care across all public healthcare sectors in Qatar was adopted. This includes Sidra Medicine and Hamad Medical Corporation and its Paediatric Emergency Centres.

An overarching system-wide sepsis committee was established and included major stakeholders within emergency medicine, critical care, infection prevention and control, and infectious disease and clinical laboratory. A paediatric multidisciplinary sepsis committee was established in 2017 and the National Paediatric Sepsis program was developed.

International evidence-based Institute for Health Improvement (IHI) methodology was adopted for program development. Major areas of the program were dedicated to the formulation of clinical practice guidelines, standardised care pathway, standardised EMR order set for all clinical areas, and ongoing education and awareness for healthcare providers at all facilities.

Sepsis simulation sessions were conducted to fill knowledge gaps and an improvement ramp module was included based on the PDSA (Plan-Do-Study-Act) strategy. A number of other PDSA initiatives were undertaken and included the following: Establish the paediatric sepsis clinical pathway and guideline (Figure 1); introduce the sepsis watchers’ concept to daily safety huddle; provide a standardized paediatric sepsis diagnostic kit; create unified paediatric sepsis antibiotics kits for all units with a safe first dose preparation protocol; develop and implement an e-learning module with education materials and paediatric sepsis order set in the electronic system.

Ongoing data collection and performance evaluation for sustainability and dissemination of information demonstrated the following:

1. Paediatric sepsis incidence varies per facility and over time. Between 30 to 100 cases/month (Figure 2). 2. Recognition: Percentage of Clinical Review, Rapid Response Team (RRT) activation, and sepsis alerts that were appropriately escalated is 91%. 3. Order set use: 26% initiating the well-established electronic paediatric sepsis golden-hour order set. 4. 42% bundle compliance (Figure 3). 5. IV antibiotics within 60 minutes of time zero showed 81% compliance.

Conclusion: Current literature suggests that systemic and supervised implementation of an evidence-based pathway for suspected and confirmed paediatric sepsis saves lives. Our data demonstrated poor bundle compliance but significant improvement is seen in the areas of early recognition and antibiotic administration within one hour. Education and awareness are key to improve performance.

Background: Haemorrhagic and ischemic stroke is the second most common cause of death worldwide, with more than 10 million cases each year¹. Hypertension, diabetes mellitus, smoking, hyperlipidemia, and aging are the most common risk factors of this cerebrovascular disease². Mortality and disability increase with the complications experienced during the early phase of stroke, such as infection, seizures, and thromboembolism³. The intensive care unit (ICU) is the most appropriate treatment environment for stroke patient care in developing countries⁴. Aims: The aims of this study were to determine the ICU and in-hospital mortality of ischemic stroke patients admitted to the ICU within 24 hours of hospitalization, and the factors that determine and affect the outcomes of ischemic stroke to predict patients requiring early ICU admission. Methods: This is a retrospective study looking at the data of patients admitted to the intensive care unit in Sultan Qaboos University Hospital (SQUH) with an ischemic stroke diagnosis within 24 hours of hospitalization from 1^st January 2013 to 31^th December 2017. Results: There were 37 patients admitted to the ICU immediately from the emergency department because of ischemic stroke during the study period. There were 14 patients who died in the ICU, 2 died in-hospital after discharge from ICU, and the others were discharged from hospital (Table 1). There were 21 male patients and 16 females, with a mean age of 61.05 years. Most patients had comorbidities and risk factors that lead to poor outcome, the most common being diabetes mellitus (70.3%) and hypertension (67.6%). However, there was no association between blood pressure and glycemic control on admission with outcome (chi-square test, p = (0.667), (0.505) respectively). CT, MRI, and CT angiography are the most common diagnostic imaging tools used for ischemic stroke. We classified CT brain findings on admission according to the location of infarction. Middle cerebral artery infarction was present in 40.5% of the patients, 18.9% had other cerebral infarction, 10.8% had brain stem infarction, and the same proportion of patients had lacunar infarction, and the rest showed no abnormality. The two main reasons for admission to ICU were coma (73.0%) and neurological monitoring post-thrombolysis (24.3%). The rest were admitted because of respiratory failure. In ICU, 48.6% received intravenous thrombolysis and the majority of patients were discharged. Others were out of the therapeutic window and had a high chance of haemorrhagic transformation. Patients developed complications after ICU admission as shown in Figure 1. There was a significant association between ICU mortality and ICU complications, (chi-square test, p < 0.05). Conclusion: The mortality of ischemic stroke patients admitted to ICU within 24 hours of hospitalization in the study period was 43.2% with higher prevalence among older and male patients. The majority of these patients had comorbidities and risk factors that lead to a poor outcome. The main two reasons for admission to ICU were impaired consciousness and neurological monitoring post-thrombolysis. The outcome can be improved by preventing such complications and therefore reducing ICU mortality. More studies are recommended to find more factors that can predict the outcome of ischemic stroke.

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

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

Background: Suxamethonium chloride (scoline) is a short acting depolarizing muscle relaxant; it was discovered early in the nineteenth century but not used in clinical practice until 1951.¹ Scoline became a popular muscle relaxant due to its rapid onset of action, quick metabolism and hence shorter duration of action. It is metabolized by cholinesterase. Scoline apnoea was described within a few years of clinical use of Suxamethonium due to inherited or acquired deficiency of the cholinesterase enzyme resulting in prolonged muscle relaxation.² Now scoline is used in prehospital and emergency intubating conditions, in pregnancy fetal distress or cord prolapse due to obvious advantages in these circumstances.^3,4,5 The aim of our study was to investigate the trends and incidence of scoline apnoea in pregnant patients. Patients and methods: All patients admitted with scoline apnoea during pregnancy in the surgical intensive care unit of a tertiary healthcare facility were included retrospectively in our study. Patients demographic data, duration of apnoea and intubation, intensive care unit stay and trends of scoline apnoea were recorded. Results: A total of 32 pregnant patients post-lower segment caesarean section were admitted to the surgical intensive care unit during the study period. The indications for general anaesthesia in the majority of patients were obstetrical emergencies (n = 23, 71.87%), refused regional anaesthesia (n = 7, 21.87%), and required general anaesthesia after the regional anaesthesia (n = 2, 6.25%) patients. Twenty-nine (90.62%) patients received premedication with metoclopramide and sodium citrate (Table 1a). Thirty (93.75%) patients received reversal combination of neostigmine and atropine. Four (12.50%) patients received fresh frozen plasma (Table 1a). The mean age of the patients was 31.7 ± 6.4 years old (minimal age was 25 years), all patients belonged to ASA class 1 and the mean duration of apnoea time was 4 ± 2.5 hours. The duration of intubation was 6 ± 4.5 hours and the length of surgical intensive care stay was 1.2 ± 0.7 days (Table 1b).

As shown in Figure 1a, the majority of patients were found to belong to the age group of 31 to 35 years (n = 12, 37.5%), followed by 9 (28.12%) patients in the age group of 26 to 30 years. It was also found that the Qatari locals and Egyptians formed the majority nationality (n = 12, 37.5% and n = 7, 21.87%) of patients (Figure 1b). The overall Arab patient population had a higher incidence of scoline apnoea compared to the Asian group of patients.

All patients were found to have cholinesterase levels below 3500 units/litre (normal range varies from 5400 to 13,200 units/litres), which is less than 70% of the normal value (Figure 2a).

There was a decreasing trend of scoline apnoea patients in recent years. From 2013 to 2016, there were no patients admitted to SICU with scoline apnoea and in 2017, only one patient with scoline apnoea was admitted (Figure 2b). Conclusion: Scoline apnoea incidence and trend in our parturient population is decreasing. The majority of our patients received premedication and reversal medication which decreases the cholinesterase levels. The decreasing trend may be attributable to increased regional anaesthesia practice and frequent use of rocuronium.

Background: Perioperative arrhythmia is a common general anesthesia complication of cardiothoracic surgeries. Sudden or acute onset of life threatening perioperative arrhythmias are rare clinical events in non-cardiac surgical patients.^1,2 Electrolytes imbalance, particularly hypokalemia and dyskalemia, is one of the main possible underlining cause for the occurrence of these arrhythmias.^3,4,5 We present two cases of severe hypokalemia leading to life threatening cardiac arrhythmias in the post-operative period. Case 1: A 30-year old healthy female patient without significant past medical history had emergency laparoscopic cholecystectomy and appendicectomy. Pre- and intra-operative periods were uneventful. Her pre-operative potassium level was 3.7 mmol/L. 18 hours post-operatively, she suddenly developed palpitations and went into ventricular fibrillation (VF) cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated followed by defibrillation which reverted the heart to a sinus rhythm. She was transferred to the intensive care unit (ICU) sedated and connected to the ventilator. In ICU, her serum electrolytes showed severe hypokalemia (serum potassium level 2.2 mmol/L) (Figure 1) so she was immediately started on 20 mmol of potassium chloride (KCl) over 30 minutes through central venous catheter (CVC) with complementary intravenous fluids with KCl. In the next 36 minutes she had four episodes of VF requiring CPR and defibrillation with a positive outcome. She received amiodarone infusion as well as continuous KCl supplementation and calcium gluconate 2 g. She received 100 mmol of KCl in 6 hours and a total of 220 mmol of KCl in 24 hours, and then she became stable. She was extubated after 48 hours. Echocardiogram and cardiac conduction studies showed no pathological changes. Cardiac conduction studies (electrophysiology study - EPS) were normal. She was discharged home and followed in the outpatient clinic. Case 2: A 78-year old known hypertensive male patient on angiotensin converting enzyme inhibitors was admitted to intensive care unit (ICU) for observation after laparoscopic cholecystectomy. Pre-operative serum electrolytes were within normal range. After one hour he started to have tachycardia and then went into pulseless ventricular tachycardia requiring defibrillation. His serum electrolytes results showed severe hypokalemia (2.4 mmol/L) (Figure 1) so this was corrected by rapid potassium chloride administration through CVC and supplementation of KCl in intravenous fluids. After 10 minutes he went into VF requiring defibrillation and a bolus of amiodarone. In the next 20 minutes he had three more episodes of VF requiring CPR and defibrillation.

In six hours he required 90 mmol of KCl to reach a serum potassium level of 3.7 mmol/L. A total of 210 mmol of KCl was needed in 24 hours. He was extubated after 24 hours. He was transferred to the ward on day 3 and discharged home on day 6, and later followed in the outpatient clinic. Conclusion: Perioperative severe hypokalemia can lead to life threatening cardiac arrhythmias. Early recognition and aggressive correction through perioperative potassium supplementation is essential for better outcome. Daily potassium level assessment and supplementation should be done in the perioperative period.

Background: Renal transplant recipients (RTR) have a comparatively lower risk of acute myocardial infarction (AMI) than wait-list patients. Cardiovascular diseases especially AMI are the leading cause of morbidity and mortality in post-renal transplant patients.^1,4 They account for up to 50% of the deaths in RTR. The incidence of AMI in RTR is about 0.2% but it is on the rise. Meticulous pre-operative assessment of cardiac status, appropriate pre-operative cardiac management, and post-operative cardiac monitoring will prevent mortality.² Recently it has been emphasized and there is ample evidence to use cardiac troponins from day zero in the post-operative period to diagnose peri-operative cardiac events like AMI.³ We report a case of post-operative myocardial infarction in a live renal donor transplant patient. This case report will serve to increase the awareness of the cardiovascular event in RTR. Case Report: A 62-year-old obese male patient known to have Type II diabetes mellitus, dyslipidemia, hypertension, end-stage renal disease (ESRD) on peritoneal dialysis, presented for live non-related donor renal transplant. In the pre-operative evaluation, his comorbidities were well controlled. His electrocardiogram (ECG) was normal and an echocardiogram revealed left ventricular enlargement and grade 1 diastolic dysfunction. Induction of anesthesia and intra-operative periods were smooth and he remained hemodynamically stable. The patient did not consent for epidural catheter insertion. Intra-operatively his iliac arteries showed multiple plaques, and his renal vessels were anastomosed with difficulty. After a 6-hour surgery, he was admitted to the surgical intensive care unit (SICU) sedated, intubated, and ventilated.

In SICU initially, his hemodynamics were stable, passing 20 to 30 ml of urine per hour, and started on 100% renal replacement with IV Ringer's Lactate. The central venous pressure was between 12 to 14 mmHg. He was rapidly weaned from the ventilator and extubated after 8 hours. Post-extubation, he was awake, stable, and resumed his oral medications.

On day 2, during physiotherapy, he complained of shortness of breath and developed severe bradycardia (24 beats/minute). Twelve-lead ECG showed ST-segment depression in the anterior-lateral leads. Within a few minutes, he went into cardiac arrest requiring CPR (cardio-pulmonary resuscitation) for 1 minute. Cardiac biomarkers were elevated (Figure 1) and chest x-ray showed pulmonary congestion (Figure 2). An echocardiogram revealed left ventricular ejection fraction of 58% and mild hypokinesia of the anterior wall. CT coronary angioram or conventional coronary angiogram was not done to avoid constrast induced injury to the transplanted kidney.

He was started on aspirin and heparin infusion. His newly grafted kidney was functioning well and he was passing 50-100 ml of urine per hour. He was hemodynamically stable and transferred to the ward on day three. From there, he was discharged home and followed in the transplant and cardiac outpatient clinics. After three months of follow-up, his kidney was functioning well and his echocardiogram became normal. Conclusion: RTR are at greater risk of cardiovascular events, particularly AMI though significantly less than the wait-list patients. Cardiac troponins should be monitored in the post-operative period as early detection of acute coronary syndrome improves their outcome.³

Background: Hamad Medical Corporation (HMC), Qatar, aims to be MAGNET accredited (Nurse Excellence Program) by the American Nurse Credentialing Center (ANCC), in addition to be an academic health center. For these accreditations it is required to establish specialty foundation courses¹ and one of these courses is the Critical Care Foundation Program (CCFP) which was designed by HMC critical care and educational experts. During the planning and curriculum design stages, the scientific and planning committee had a thematic focus on; learner-centeredness, active learning, and eustress learning strategies^2,3. Methods: Stressful learning has negative impact on achieving learning outcomes^2,3. For effective implementation of learner-centeredness and eustress learning, the CCFP design embedded different interactive teaching and assessment strategies including but not limited to; case-based teaching, competency-based teaching, interactive group learning conversations, and demonstration workshops^1,2,4,5. To get the CCFP certificates learners should attend the whole program. However, there is a clinical attachment (competency assessment) and the CCFP was designed as eight teaching days over 8 weeks (one day per week). The program design was planned purposefully as the critical care nurses are given enough time to go to the critical care clinical fields to do the competency assessment for related CCFP teaching topics. Eight hundred critical care nurses have attended CCFP over the last four years. During the program, learners were given a chance and appropriate time to consolidate their knowledge and skills, in addition to bridge the gap between theory and practice, and to become competent and specialized ICU nurses with normal and tolerable levels of stress (eustress)^3–5. As per the Qatar Certified Healthcare Practitioner Continuing Professional Development requirement, all course participants completed an evaluation form, which we administered online and combined with the participants’ ability to download the program completion certificate. The data from the participants’ evaluation forms was reviewed by the course scientific and planning committee which then was used to make further recommendations. Results: The CCFP curriculum design was helpful and effective in controlling critical care nurse's stress level which was evident by learner's self-reporting feedback and assessment tools (Table 1). Moreover, the program design was effective for active learner's engagement which was evident by the learner's feedback, educational experts, and peer review reports (Tables 1 and 2). A total of 800 nurses underwent the critical care specialty competency assessment process, and they were signed off as competent in all the domains assessed. Conclusion: Eustress learning allocates the learner at the center of the learning process and provides better learning outcomes. The design of this teaching curriculum which integrates different modalities of teaching and assessment methods helps learners to be actively involved in the learning and assessment process. Considering flexible and evidence based assessment methods in addition to written exams is recommended to decrease stress among learners. Reflection, and competency clinical attachment are recommended teaching and assessment methods to decrease learning and assessment stress levels, and to promote the effectiveness of the learning and teaching process.

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

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

Background: Pre-eclampsia/eclampsia is a life-threatening disease with considerable risks on maternal and neonatal health. Globally, it affects between 2–8% of all pregnancies. Worldwide, approximately 63,000 pregnant women die each year due to pre-eclampsia/eclampsia. The MAGPIE (Magnesium sulphate for Prevention of Eclampsia) trial stated that the risk of developing convulsions was lowered significantly (58%) in severe pre-eclampsia patients who received magnesium sulfate in comparison to the placebo group.¹ The exact mechanism of action of magnesium sulfate (MgSO4) is not completely understood, blocking calcium channels and decreasing availability of calcium for smooth muscle contractions has been suggested. Pritchard advocated that therapeutic concentration of MgSO4 should be between 2-4 mmol/l.² Despite strong evidence of the effectiveness of MgSO4, concerns have been expressed about the risk of hypocalcemia to the patient when used alone or concomitantly with nifedipine as both of them affect calcium metabolism.³ Hypermagnesemia causes hypocalcemia by inhibiting parathyroid hormone secretion and increases urinary excretion of calcium. Severe hypocalcemia is a life-threatening condition and may lead to focal or generalized tonic muscle cramps, convulsions, arrhythmia, and laryngospasm and stridor which is common in the pediatric population but has also been reported in adults.⁴ A case of symptomatic hypocalcemia secondary to hypermagnesemia is extremely rare, and to the best of our knowledge, only a few cases have been reported.⁵ We believe this is the only case in the literature with stridor and potential airway obstruction. Case: A 30-year old black South African woman, gravida 5, para 3+1, presented with severe preeclampsia (BP 215/145 mmHg, proteinuria +2), and preterm premature rupture of membrane at 33 weeks of gestation. General and obstetric examinations were unremarkable. Laboratory parameters on admission showed acute kidney injury, anemia and elevated lactate dehydrogenase and alkaline phosphatase. Other investigations were normal (Table 1). She was admitted to the high dependent unit and received 10 grams of intramuscular MgSO4, followed by continuous intravenous infusion at a rate of 2 g/hour for 24 hours. Her blood pressure dropped to 145/95 mmHg. Three hours post-admission, her blood pressure raised to 186/124 mmHg and was controlled with a labetalol intravenous infusion and nifedipine 10 mg orally. Her blood pressure then dropped to 150/90 mmHg. Six hours post-admission, the patient had an uneventful emergency caesarean section under spinal anesthesia for fetal distress. Nine hours post-admission, the patient had dyspnea, respiratory distress, and inspiratory stridor, and chest examination was unremarkable. While checking her blood pressure, the patient had carpopedal spasm (Trousseau's sign) and masseter muscle spasm (Chvostek's sign). MgSO4 infusion was stopped. She received 10 ml of 10% calcium chloride over 10 minutes and responded dramatically to resuscitation and calcium chloride. Investigations (arterial blood gas, FBC, urea and electrolytes) were performed and showed low ionized calcium 0.89 mmol/l and her magnesium level was 2.74 mmol/l. Conclusion: Although MgSO4 is considered as the treatment of choice for the prevention of convulsions in pre-eclampsia/eclampsia patients, concerns have been raised regarding the risk of severe hypocalcemia, especially when used concomitantly with calcium channel blockers. Prospective studies designed in a controlled fashion are needed to assess the safe combination of magnesium sulfate and nifedipine.

Background: Globally there have been many initiatives to enhance the number of organ donors.¹ The number of individuals waiting for a transplant is significantly higher than the number of available donated organs and the gap continues to widen. In the United States, it has been reported that over 106,000 individuals are awaiting organ donation.² The family plays a crucial role in the organ donation process. Therefore, it is important to understand the organ donation experiences of family members in the Arab world which extends from the Atlantic Ocean in the west to the Arabian Gulf in the east, and from the Mediterranean Sea in the north to Central Africa and the Indian Ocean in the south. There are some challenges surrounding organ donation due to ethical, legal, and social problems. Besides that, religious and traditional issues are more common in the Middle East and Gulf region. In the Middle East, organ donation after brain death or for living donors have less family members’ willingness and acceptance.³ Family members of organ donation cases face many challenges before accepting the terms of donation. In reference to this issue, many studies stress the need for family involvement, education and awareness programs in early stage of brain death, even in acute cases that are subject to time constraints.

We aim to examine findings of an integrative literature review and explore families’ decision-making process related to organ donation of brain dead patients or living donors, posing the question “Do we have to tell the patient's family everything concerning organ donation?” Answering this question will help healthcare providers to understand factors, barriers and culturally sensitive aspects that are leading to the willingness and acceptance of organ donation.⁴Methods: The integrative literature review was based on Cooper's five-stage process.⁵ These stages clearly summarized by Russell include problem formulation, data collection or literature search, evaluation of data, data analysis, and interpretation and presentation of results.⁶ To determine the sample of the review, published scientific papers in indexed periodicals electronic databases, such as CINAHL, Medline, Google Scholar with Full Text and PubMed from 2009-2019 were searched. Results: The result of the review highlighted the importance of different aspects that lead to acceptance of organ donation. We anticipate that the results of this review will increase awareness of the patients’ families concerning organ donation experiences and its impact on the decision-making process. In addition, it will help healthcare professionals and policymakers to consider new strategies, ways of thinking, and communication strategies that can be adopted with patients’ families concerning organ donation. Organ donation campaigns can help raise public and healthcare providers’ awareness of the benefits of such programs. Conclusions: This review identified that public orientation and family support is the ideal approach for family consent which often remains the only way for organ donation to be made possible. In addition to that, there is a need for the development of supportive policies and continuous education and training programs for healthcare providers and proper utilization of resources to improve the organ donation process.

Background: Sepsis has been identified as a time critical and life-threatening condition resulting from the body's own systemic response to infection leading to multi-organ dysfunction and failure, and remains a major frontrunner in the morbidity and mortality of critically ill patients^1–3. The 2016 Surviving Sepsis Campaign¹ identified that similar to patients with polytrauma, stroke and acute myocardial infarction, the early identification and timeous delivery of appropriate treatment for patients with sepsis could improve patient outcomes and decrease mortality rates^1,4. Prehospital sepsis screening tools could provide a systematic approach to critically ill patients in order to identify those patients with a high index of suspicion for sepsis and allow for early and aggressive management.

Methods: A literature review was conducted for the period January 2011 to September 2017. A database search was conducted via the electronic databases Ovid MEDLINE (without revisions), CINAHL and The Cochrane Library. The websites ScienceDirect, Wiley Online Library, British Medical Journal (BMJ) and Google Scholar were also used in the search for literature. Full search strategies are detailed in Table 1. The selection and rejection of all articles can be reviewed in Figure 1.

Results: All articles identified for full review (n = 13) were between the period January 2011 and September 2017. The three most common methodologies identified were systematic review (n = 3), prospective cohort study (n = 3) and prospective observational study (n = 3). Other methodologies included literature review (n = 1), retrospective cohort study (n = 1), retrospective analysis (n = 1), and retrospective cross-sectional study (n = 1). Through literature analysis, three main areas of interest were identified in which articles were reviewed: the early recognition of sepsis by Emergency Medical Services (EMS) staff (n = 2), the early recognition of sepsis using a prehospital sepsis screening tool by EMS (n = 6), and the impact of EMS sepsis recognition and management on patient outcomes (n = 4). A comparison summary of the various sepsis screening tools can be viewed in Table 2.

Conclusion: Previous literature has described EMS transport rates of approximately 3.3 sepsis patients per 100 and approximately 40% of septic patients admitted having been transported by EMS⁵. Despite this relatively high prevalence, the review identified that recognition of sepsis by EMS personnel was poor. The use of various sepsis screening tools showed improved recognition by EMS but validation studies on the accuracy of these tools is required. In patients in whom a screening tool was used and early pre-notification given to receiving facilities, a decrease time to definitive management of these patients was identified. These varied findings in outcomes of septic patients transported by EMS identifies the need for further studies on EMS recognition of sepsis and the impact it has on the outcomes of these patients. A specific prehospital sepsis screening tool could possibly assist in the early recognition of sepsis. Pre-notification to receiving facilities could allow the facility to prepare for EMS arrival and continue aggressive early goal directed therapy (EGDT) as required.

The author acknowledges the possibility of publication and selection bias within this review due to single author selection and only English studies being included.

Background: Diuretics, ACE inhibitors or ARB, beta-blockers, and aldosterone antagonists are well established guideline directed medical therapies (GDMT) used in patients with left ventricular reduced ejection fraction (LVrEF) heart failure (HF). Hospitalization is an important marker of poor heart failure prognosis^1–2. Scientific reports have shown that ivabradine reduces cardiovascular outcomes (cardiovascular death and hospitalization due to worsening heart failure symptoms) in HF patients³. However, in the SHIFT trial 8% of the ivabradine study group were from Asia, with 3% from other races and Caucasians making up the majority of the sample (89%)³. No previous studies have investigated the effect of ivabradine on cardiovascular outcomes among Arabs and non-Arabs from Asia and Africa or Middle Eastern countries in general. The aim of this single-center retrospective study was to assess the effect of ivabradine in addition to GDMT in a group of HF patients with a heart rate (HR) of more than 70 bpm, LVrEF (EF < 40%) and New York Heart Association (NYHA) class II-IV, compared with another group of patients not taking ivabradine with HR of more than 70 bpm, LVrEF and NYHA class II-IV on GDMT. Methods: The study was a retrospective cohort study. It was conducted in the Heart Hospital (HH) at Hamad Medical Corporation (HMC) in Qatar. All patients registered in the HF clinic from April 2015 to September 2016 were enrolled in the study. They were either exposed or not to ivabradine (Figure 1). The primary outcomes studied were the associated risk, number and length of hospitalizations due to worsening HF, and cardiovascular mortality. The secondary outcome was mortality due to all causes. Patients’ follow up records for 18 months after recruitment were observed. Baseline characteristics were collected at enrollment. Logistic regression model was applied to assess both hospitalizations and cardiovascular mortality. The number of hospitalizations due to worsening HF was modeled using a Poisson regression model. Length of hospitalization (in days) was estimated and assessed between groups by a negative binomial regression. Results: The study included 111 patients (Figure 1): 37 (33.94%) ivabradine patients and 74 (66.67%) non-ivabradine patients. The number of ivabradine patients hospitalized were 23 (62.16%) vs 54 hospitalized non-ivabradine patients (72.97%) (OR 0.43, 95% CI 0.16-1.015, p = 0.094) (Table 1). Days of hospitalization for the ivabradine group were 464 (41.28%) vs 660 (58.72%) for non-ivabradine (IRR 1.63, 95% CI 0.79-3.38, p = 0.187). The death rate in ivabradine patients was three (two patients died due to CVD and one due to other causes) and it was also three in non-ivabradine patients (one due to CVD and two due to other causes). Testing the outcome by the factor of ethnicity instead of treatment group had different results. The number of Arabs admitted was 55 (78.57%) compared to 22 non-Arabs (53.66%) (chi-square, p = 0.006). The number of Arabs admitted in the ivabradine group 19 (76%) was significantly higher than for non-Arabs 4(33.33%) (Pearson chi-square, p = 0.012). Conclusion: The results of the study are not generalizable but showed that ivabradine patients with HFrEF along with GDMT had less risk of hospitalizations but lengthier stays and increased count of hospitalization compared to non-ivabradine patients. Though the study did not aim to explore the differences between Arab and non-Arab patients, significant differences were found in the statistical analysis highlighting the need for further research to investigate the reasons behind these differences.

Background: Pulmonary emboli (PE) represents an extended spectrum of diseases. 10% of submassive PE progress to massive PE, and while overall mortality is around 5%, it can reach 30%,¹ highlighting the potential severity of submassive PE. Treatment of low and high-risk PE is rather straightforward. However, treating intermediate risk PE is challenging due to the potential risks associated with aggressive therapy. We assessed the effect of adding thrombolytic therapy to standard treatment with heparin on short-term mortality, clinical deterioration, and bleeding in intermediate-risk PE cases. Intermediate-risk PE in this systematic review is objectively confirmed PE either by computer tomography (CT) or ventilation/perfusion (V/Q) scan in normotensive patients (systolic blood pressure ≥ 90 mmHg) with evidence of right ventricular strain by echocardiography or CT with or without evidence of myocardial injury by raised cardiac biomarkers.²Methods: A literature search was conducted using PubMed, OvidSP Platform, Google Scholar, BestBETs, The Cochrane Library - Databases, American College of Chest Physicians (ACCP), American Heart Association (AHA), European Society of Cardiology (ESC), American College of Emergency Physicians (ACEP), and NICE guidelines from 1946 to the 21^st March 2018. References of retrieved articles were reviewed for other possibly related citations. The randomized controlled trials (RCTs) were studied and appraised using the Cochrane risk-of-bias tool (Table 1). Results: From 66 potentially relevant studies, six RCTs were published between 2002 and 2017 and included in this systematic review (Table 2). A total of 1568 patients were enrolled: 747 received thrombolytic therapy with alteplase (two trials, 155 patients) or tenecteplase (four trials, 592 patients), and 821 were treated with heparin only. None of these RCTs proved that adding thrombolytic therapy to standard anticoagulant treatment statistically decreased early mortality. The five studies looking at clinical deterioration proved that thrombolysis was beneficial. Five out of six RCTs resulted in a non-significant difference in major bleeding prevalence. Only the PEITHO³ trial proved the opposite. The incidence of minor bleeding was significantly higher in the four studies in which it was measured (Table 3). Conclusions: Currently, there is inadequate evidence to support the use of systematic thrombolysis for patients with acute intermediate-risk PE. Although it may prevent clinical deterioration which necessitates escalation of treatment in the short term, it comes with increased risk of bleeding. Individual risk-benefit patient assessment and shared decision making may be wise until better evidence to proceed otherwise is demonstrated. Larger clinical trials concerning reduced thrombolytic doses and prolonged infusion rate is essential.

Background: Airway management of the critically ill patient is challenging. An audit of airway management in the UK reported higher incidence of significant airway complications (death and hypoxic brain damage) in the Intensive Care Unit (ICU) compared to regular anesthetic practice in the operating theatre.¹ Virtual bronchoscopy (VB) can be valuable in airway management in the ICU. Methods: Virtual reality (VR) emerged in the clinical field 20 years ago^2,3 utilizing graphics, high-end information technology, advanced sensors, and human-computer interfaces to create an immersive and interactive artificial environment. Conversion of standard radiological Computer Tomography (CT) images as computer-generated simulation of airway anatomy is referred to as VB or virtual endoscopy (VE).^2,3

VB allows the display of high-resolution airway images down to 6/7th bronchial subdivisions and simulates findings of traditional fiberoptic bronchoscopy (FOB)³ (Figures 1 and 2).

The indications of VB in ICU include evaluation and management of tracheobronchial stenosis, airway trauma, inhalation injury, foreign body aspiration, tracheostomy tracheoesophageal fistula (TOF) (Figure 3), and bronchopleural fistula (BPF)². Results: VB has several advantages including non-invasiveness, non interruption of mechanical ventilation or potential loss of airway, and no need for specific patient preparation. In addition, there is no exposure to contrast and it can be accomplished within a minute. VB allows airway evaluation of intra- and extra-luminal airway structure from all angles in isolation from its surroundings. Being operator-independent is a major advantage of VB.⁴

FOB has significant limitations and potential complications. These include limited access via severe stenosis, inability to evaluate caliber and morphology of post-stenotic airway, limited information about airway surrounding structures in addition to risk of hypoxia, hypercarbia, and de-recruitment. Notably there is absence of bronchial colour or texture information, no endobronchial gesture such as bacterial sampling is possible, there are many false negatives and false positives, and the reproducibility of the measurements is still mediocre. Adequate sedation is needed during FOB with associated hazards. Moreover, risks of airway trauma, bleeding, pneumothorax, infection, and increased airway pressure with FOB have been observed.^2–4

In tracheobronchial stenosis, VB showed sensitivity of 63–100% and specificity of 61–99%, allows examination of the post-stenotic section of tracheobronchial tree and provides information about extra-luminal pathology.³ VB is safe and well-tolerated by critically ill patients and does not pose a risk of contamination or infection of critically ill immunocompromised patients.³

3D reconstruction and VB can be performed either by the radiologist, anesthetist or surgeon on an appropriate workstation utilizing widely available software to generate an internal simulated view of the airway or the pathology. This can be utilized to formulate an airway management plan in critical and challenging situations.^4,5

However, retained mucus or blood mimic tracheobronchial stenosis. VB cannot be utilized for evaluation of pulmonary mucosa, biopsy, or pulmonary lavage. Dynamic changes, such as vocal cord palsy can be challenging to appreciate using VB. In addition, VB mandates transfer of critically ill patients to the radiology department and exposure to radiation.³Conclusion: 3D and VB volume rendering of CT images of the airway can provide anesthetists and intensivists with an alternative view of the airway in ICU settings. This can be utilized to formulate an airway management plan in the most demanding conditions.

Background: Child fever or puerperal sepsis is a significant cause of maternal morbidity and mortality. It is a preventable maternal postpartum complication.¹ Group A streptococcus (GAS) infection remains a significant cause for postpartum sepsis as it causes septic shock and multiple organ dysfunction (MODS). There has been a resurgence of severe puerperal GAS infections over the past two decades, although rare, it must be recognized early and treated aggressively. GAS is a common bacteria causing necrotizing fasciitis (NEF) in our region,² but it caused NEF in only one postpartum patient which is a rarity.^3,4,5 We report a case of puerperal GAS infection-causing NEF where the patient underwent multiple surgical debridements complicated with septic shock and MODS, and had a fairly positive outcome.

Case presentation: A 26-year old female presented to the emergency department 5 days postpartum with fever, tachycardia, tachypnea, borderline blood pressure, vaginal discharge, and severe pain in the right leg. Her physical examination revealed reddish discoloration of the right lower leg, which was edematous, warm, and extremely tender. The episiotomy wound looked dirty and infected. She had leukocytosis (29.2 × 10³/μL), thrombocytopenia (44 × 10³/μL), C-Reactive protein was elevated (322 mg/L), and serum lactic acid was 3.8 mmol/L. Her hepatic and renal parameter were elevated. She had a deranged coagulation profile. Post-partum sepsis was suspected and blood cultures were done. She was started on Tazocin® (Tazobactum+piperacillin), supplemented with oxygen, and resuscitated with intravenous fluids.

She was immediately taken for emergency surgical intervention, right leg debridement, and fasciotomy with exploration of the episiotomy wound was performed. Surgical findings were dirty colored fluid collection and loss of facial resistance which corroborated with NEF. Necrotic tissues were sent for histopathology and cultures, and clindamycin was started. Intraoperatively the patient became unstable, requiring double vasopressor (noradrenaline and vasopressin) to maintain the hemodynamics. Postoperatively the patient was kept sedated and ventilated in the intensive care unit (ICU). She required four debridements in the next two days despite which her right leg was not improving. Magnetic resonance imaging showed necrotizing fasciitis of the right thigh and leg. Tissue biopsy confirmed the diagnosis. Her blood and tissues showed growth of group A streptococcus. With family agreement, she underwent above right knee amputation, lateral and medial thigh compartment fasciotomy, and debridement on day five. She was oozing from the fasciotomy wounds and needed resuscitation with blood and blood products. She started to show signs of improvement and was weaned off from vasopressors and ventilator. Hepatic and renal functions improved (Figure 1 and Table 1). She was extubated on day 12, awake, hemodynamically stable, tolerated oral feeding, and was transferred to the surgical ward on day 19. She was discharged home on day 24 and was followed in surgical outpatient clinics.

Conclusion: Despite developments in infection control and strict aseptic precautions, GAS puerperal sepsis remains a potentially life-threatening infection especially when they present with rare conditions like NEF in the postpartum period. Early diagnosis, aggressive surgical management, and supportive medical care are important for a positive outcome.

Background: Management of pain in the prehospital setting is an important priority for prehospital clinicians, yet is often underestimated, either due to poor pain assessment, under dosing and inadequate provision of analgesia^1,2. A femur fracture is considered a painful injury and as such, should be managed with effective analgesia. Pain is associated with multiple negative physiological effects which may potentially worsen a patient's clinical condition¹, further highlighting the importance of providing effective analgesia. Vassiliadis et al., highlighted that patients with a femur fracture receive only moderate analgesia in the prehospital setting and this requires a focused strategy to improve the care received by these patients³. A retrospective audit of the Hamad Medical Corporation Ambulance Service (HMCAS) electronic patient care records (ePCR) highlighted the low frequency of prehospital analgesia for the management of femur fractures (October 2016 – December 2016). The provision of three pharmacological agents (Methoxyflurane, Fentanyl and Ketamine) which are the primary analgesics used by the HMCAS for the management of pain associated with femur fractures was reviewed. These drugs are often used together in a multimodal strategy to manage pain effectively. A multimodal approach to managing trauma pain has the benefit of improving efficacy with multiple mechanisms of action, limiting the number of doses required of a single drug, as well as reducing the risk of side effects⁴. The aim of this study was to improve prehospital analgesia for femur fractures, by means of introducing a purpose-designed trauma CPD training course. Focused training through the means of high fidelity simulations and simple skills training leads to improved performance and an increase in knowledge gained by the practitioner⁵, resulting in improved and safer care delivered to patients. Methods: An intervention consisting of a theoretical, individual skills and simulation-based mandatory trauma CPD training session for all operational prehospital care providers was implemented over a three-month period (January 2017 – March 2017). The eight-hour trauma CPD training session focused on managing major trauma with specific focus on femur fracture identification and optimization of analgesia (Figure 1). Following the intervention period, a repeat retrospective audit of the ePCR database was conducted to identify any improvement in the frequency of prehospital analgesia for patients with femur fractures (April 2017 – June 2017). Results: The mean provision of prehospital analgesia for a femur fracture in the pre-intervention stage was found to be suboptimal (Methoxyflurane 61%; Fentanyl 21%; Ketamine 12%). Whereas, following the intervention period, the mean provision of prehospital analgesia for femur fractures increased significantly (Methoxyflurane 100%; Fentanyl 30%; Ketamine 52%). See Figure 2. Conclusion: This study found that focused trauma training is an effective means to improve prehospital analgesia for femur fractures as well as overall patient care. Introduction of the trauma CPD training session resulted in an improvement in the management of pain associated with a femur fracture. Significant room for improvement still exists and prehospital analgesia should continue to be developed. Further research is still required.

Background: A journal club is a forum to debate and review clinical practice using a number of models to gauge the strength of evidence associated with the clinical practice. A large body of evidence supports the importance of journal clubs as a method to improve patient outcome by enhancing the implementation of evidence-based practice and professional development in the clinical setting^1–3. Journal club activities have been recommended by the Hamad Medical Corporation (HMC) Critical Care Nursing Network (CCNN), Qatar, and started in the critical care areas of Hamad General Hospital for different critical care specialties such as trauma, surgical, and medical ICUs since 2014. Methods: The journal club is a 1-hour monthly critical care educational activity for HMC critical care nurses. A flyer promoting the article to be discussed is shared with the critical care nurses one week prior to the scheduled date and each session is attended by 15–20 nurses. Participants gain continuing professional development (CPD) credits for each session they attend. The articles discussed cover patient safety and critical care clinical practices. A structured review of the selected articles is facilitated by an expert educator with a research background. The strength of the evidence to change current clinical practice will be evaluated in a group discussion format (Table 1). At the end of each journal club activity, the facilitator summarizes the learning points, recommendations, and the action plan if the group believes changes to current clinical practice are recommended³. Results: Around 50 journal clubs have been conducted in the critical care units of HMC with a total attendance of 1100 nurses. The journal club activity encouraged critical care nurses to establish the first nursing clinical research team in critical care areas of HMC (Table 2). Additionally, it had a positive impact on improving the professional development and competency level of the critical care nurses which were assessed and evaluated by HMC critical care competency assessors through applying the specialty critical care competency checklist. Finally, implementation of the journal club activity and reviewing best available evidence and research literature led to improvements in clinical practice (Table 3). Conclusion: Implementation of the journal club activity helped in developing critical care nurses’ awareness on current research studies and best available evidence, in addition to keeping them up-to-date with new findings, practices, and critical care trends. The journal club with its structured review questions has proven to be an effective way of evaluating the strengths of the evidence presented in the reviewed articles and sometimes led to changing our critical care clinical practice. It also contributes to improving nurses’ ability to critically appraise research articles. Furthermore, it promotes the implementation of new knowledge gained in clinical practice which is expected to improve patient safety and outcomes.

Background: Hemodialysis patients are at higher risk of contracting infections particularly methicillin-resistant Staphylococcus aureus (MRSA). MRSA is a serious infection and could be fatal within hours to days if undiagnosed. Dialysis catheter commonly known as permacath is a tunnel catheter used for maintenance hemodialysis which is associated with serious complications, especially infections and thrombosis. Different methodologies were designed and tested to determine the relation of infection with permcath. The use of a cuff was thought to prevent catheter related infections but none proved beneficial.¹ This finding was supported further in a systematic review conducted in 2009.² Usage of permacath is on the rise despite awareness of its higher risk of morbidities and mortalities which is contrary to the slogan of Fistula First Initiative.³ We aimed to evaluate the prevalence of MRSA infections in hemodialysis patients with tunneled hemodialysis catheters. Methods: This is a retrospective, qualitative cross-sectional and non-experimental single center study conducted at Sultan Qaboos University Hospital (SQUH) Hemodialysis Unit over eight years. Inclusion criteria include: Adult patients >18 years of age with diagnosis of end stage renal disease requiring hemodialysis. Exclusion criteria included age < 18 years old and patients on peritoneal dialysis. Records of hemodialysis patients from 1^st January 2010 through 6^th May 2018 were retrieved through TrackCare (electronic medical records). The patients were divided into two groups. Positive MRSA infection (defined as a positive Gram stain with cocci in clusters and which was further confirmed by positive DNA polymerase chain reaction (PCR) for MRSA) either from the periphery or central line or pus swab from the catheter tunnel site at the time of admission or during hospitalization.⁴ The remaining screened patients were classified as negative MRSA. Informed consent was waived as it is a retrospective study and our work was based on collecting information from TrackCare. All patients’ data were de-identified prior to analysis. Results: From 2010 to 2018, 1356 hemodialysis patients were identified within the hospital information system (HIS). Based on our inclusion criteria, a total of 1064 screened patients were included in our study. Those remaining who were not screened were been excluded. Fifteen patients were detected positive with MRSA infection (Figure 1), 12 patients had permacath and three had arteriovenous fistula (AVF). Overall, the prevalence of MRSA infection was 1.1% (12/1064) in hemodialysis patients with tunneled catheters. Conclusions: In our study, the MRSA prevalence rate was lower than the international reported statistics (4.2–6.5 per 100 patients).⁵ This supports the use of adequate infection control policies and practices adopted in the unit. We propose that fistula should be the preferred access option for the maintenance hemodialysis. However, in cases where catheter is the only option, due to whatever reason, then using chlorhexidine impregnated dressings in addition to standard catheter care techniques result in reduced infection incidence. Furthermore, use of topical antibiotics at catheter exit sites can reduce the risk of infection.

Background: Extracorporeal Cardiopulmonary Resuscitation (ECPR) has been increasingly usedfor failed conventional CPR. Successful use in sudden major vessel rupture hasn't been reported. Cases of community-acquired methicillin-resistant staphylococcus aureus (CA-MRSA) pericarditis associated with major vessel rupture however are limited in number¹ with a reported mortality of 20–30%.² Here we present a case of CA-MRSA pericarditis that was complicated by aortic rupture in which ECPR was successfully utilized. Methods: A four-year-old boy presented with fever, abdominal pain and vomiting for one day. He had a fall from a tricycle with potential abdominal injury the day before and had a small gluteal abscess present for four days. Examination showed slight tachycardia, mild tachypnea and low-grade fever. CBC showed neutrophilic leukocytosis. Initial chest x-ray, electrocardiogram, and abdominal tomography scan were normal. He was managed with analgesics and covered with ceftriaxone. Chest CT done on the third day due to tachypneashowed pericardial and bilateral pleural effusions. Echocardiography showed a large pericardial effusion with a collapsing atrium, indicating tamponade. Emergency pericardiocentesis retrieved 120 ml of serosanguinous fluid. A pigtail catheter was left in-situ. Intravenous vancomycin was added to the antibiotic coverage. Pericardial fluid culture grew MRSA. He showed clinical improvement, and inflammatory markers showed progressive decrease. Pericardial drain was removed after five days as the drained fluid became minimal. Subsequent echocardiograms showed only debris in the pericardial space.

Five days later while looking well, he coughed, desaturated, and became hemodynamically unstable. He was resuscitated for 55 minutes, during which he mostly had pulseless electrical activity. Bedside sternotomy was done during resuscitation to initiate central ECMO as part of ECPR. The pericardial sac was bulging, and when opened, around 500 ml of fresh blood with clots came out. Blood jets were coming from the ascending aorta which was found ruptured and covered with a thick layer of organized pus. Pus was removed from around the superior vena cava, right ventricle and ascending aorta, and the aorta was sutured.The patient was connected to femoral VA ECMO as the aortic wall was very friable. Results/outcome: The patient was decannulated from ECMO after 3 days and discharged from hospital after 2 months. At discharge, he was alert, communicating and had generalized weakness. MRI brain showed hypoxic ischemic changes. Conclusion: This is the first pericarditis case reported to develop aortic rupture, and the first to survive after a pericarditis-associated major vessel rupture, with utilization of ECPR and timely surgical repair. One case ofMRSA purulent pericarditiswith pulmonary trunk rupture was reported in a 68 year old woman who expired due to massive bleeding and difficulty of surgical repair.³ Although pericardiectomy should be considered from the outset in the management of purulent pericarditis,⁴ surgical intervention was not considered initially as the aspirated pericardial fluid was visually serosanguinous andsubsequent echocardiograms didn't show reaccumulation. Prior to admission, there was a small gluteal abscess, which probably served as the portal of entry for the MRSA but was dry at the time of admission and was not sampled.

Necrotizing fasciitis (NF) is a surgical emergency characterized by a fulminant course and high mortality rate.^1,2 NF is a severe form of soft-tissue infection. When NF is complicated with acute myocardial infarction (AMI), acute respiratory distress syndrome (ARDS), and acute kidney injury (AKI), the patient's chance of survival are diminished significantly.^3,4 We present a case of NF of the abdominal wall with acute non-ST segment elevated myocardial infarction (NSTEMI). No such case has previously been reported according to our review of the literature. Case: A 52-year-old female with a known case of hypothyroidism presented to the emergency department with severe abdominal pain for two days. She gave the history of abdominal hernia repair ten days back. She had sinus tachycardia but other vitals were normal, with no fever or leucocytosis. Computed Tomography (CT) of the abdomen showed anterior abdominal wall collections. Septic workup was done, cefuroxime and metronidazole were started. Her abdominal wall collection was drained under image guidance. After a few hours, her blood pressure dropped and was not responding to fluid challenges so a noradrenaline infusion was started and she was transferred to the surgical intensive care unit (SICU). Her blood work showed lactic acidosis. Her abdomen was tender all over with swelling and induration of the abdominal wall. Antibiotics were changed to meropenem and clindamycin to broaden the spectrum in view of the septic shock and she was immediately taken for exploratory laparotomy. The operative findings were suggestive of necrotizing fasciitis of the anterior abdominal wall and a bold and thorough debridement was done. She was kept intubated and ventilated for a second look and further debridement was conducted after 24 hours.

Six-hours post-surgical debridement, electrocardiographic (ECG) changes were noticed, 12-lead ECG showed ST-segment depression in leads II, III, aVF, and V5-6, with raised cardiac biomarkers and lower cardiac index (Figures 1 & 2), diagnosed as NSTEMI. Heparin infusion, aspirin, and clopidogrel were started. Echocardiogram showed moderate left ventricular systolic dysfunction (ejection fraction: 45%) with septal dyskinesia. Dobutamine infusion (guided by the PiCCO study) was started, which improved her hemodynamic parameters. CT coronary angiography was inconclusive. These findings suggested that she suffered Type II myocardial infarction due to the stress. She developed oliguria which improved with the restoration of hemodynamics. Her lung condition also deteriorated (PaO2/FiO2 ratio dropped to 100), requiring maximum ventilatory support and she was managed as per ARDS guidelines.⁵ Blood culture showed growth of Group F Streptococci and Prevotella melaninogenica. Meropenem was continued as the growths were sensitive to it.

By day six, she started to be weaned off from the ventilator and vasopressors. She was extubated on day nine and transferred to the ward on day ten. She was later discharged home to be followed up in the surgical outpatient clinic. Her length of stay was 15 days. On a six-month follow-up, she was functionally independent, on aspirin, clopidogrel, and thyroxin therapy. Conclusion: Our patient had NF of the anterior abdominal wall leading to septic shock and complicated by NSTEMI, ARDS, and AKI. Timely source control, close monitoring, quick, and effective interventions appear to have resulted in her excellent recovery.