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

Social media has transformed the way we communicate with each other in the last decade or so. Out of 4 billion internet users, more than 3 billion are on social media. The medical community has also been transformed in terms of how we approach this vast medium of information. Microblogging sites like Twitter are beneficial in the way we share and disseminate professional knowledge. The critical care community has recently gained a lot of pace on the social media platform and are showing their presence in numbers.¹ Although use of social media in critical care has great potential to benefit its users, it comes with its own challenges. This includes inaccurate information and slow adaptation. So the question arises: How can the critical care community make the best use of social media resources while ensuring the right knowledge is shared and practiced, and patient confidentiality is always respected?

Twitter has been used as a medium to not only spread information but also as a platform to teach critical care physicians and nurses. There are elements which affect the usability, efficiency, effectiveness, and widespread acceptance of Twitter as a teaching aid.² FOAM, free open access medical education, is an online movement taking place across social media, blogs, and podcasts that is challenging traditional methods of medical education.³ FOAM provides a free platform for learners to not only receive information but also share it with other users. It gives the learner a chance to tailor their resources according to their individual needs. In addition, learners can reach out for assistance from the source much more easily as compared to traditional ways. But concern has been raised on how to best approach these resources as they do not undergo vigorous checks like peer reviewed articles. Check and balance of the validity of the provided information is often left up to the learners discretion. It can leave educational gaps at times and may not be applicable worldwide. Similarly, declaration of conflict of interest is not mandatory on these platforms hence it is often impossible to identify commercial bias.

It can be quite difficult to keep track of all the continuing professional development hours spent on social media but new applications are being developed, which can help. While on social media, all the norms and etiquette of healthcare professionalism should be maintained such as patient confidentiality and appropriate interprofessional relationships. There are evolving tools to evaluate the quality of various resources like SMi (Social Media Index)⁴ and HONcode (Health on the Net Code of Conduct).⁵

Social media, when used correctly, can be effective for self-directed learning, holding discussions with other critical care and healthcare professionals while reflecting on newly-acquired knowledge. Although the information must be used with due care, as the peer review is mostly inexistent in social media as people can post what they want, it is one of the most exciting and evolving areas in critical care practice.

Site-initiated clinical trials are challenging, particularly with vulnerable populations like ICU patients. But they can be useful if you can answer “Yes” to these questions: (1) Could the answer change practice? (2) Does my ICU see enough of these patients to answer the question? (3) Can I treat both the investigational and control group patients in a fair manner? Other approaches to ICU clinical research, such as joining another multicenter clinical trial and observational (prospective or retrospective) studies whose answers have explanatory power may also be valuable.

Regarding changing practice: The trial's answer should be important enough that any intensivist treating such a patient would care about it. Examples of questions that probably aren't important enough are: (1) Is there a difference in ARDS outcome if the tidal volume is 4, 6, or 8 mL/kg?, (2) Is knee-high pneumatic compression inferior to thigh-high pneumatic compression for thromboembolism prophylaxis in anticoagulant-contraindicated patients?, and (3) Do piperacillin-tazobactam and cefepime have equivalent efficacy for empiric coverage of hospital-acquired infections? The first question probably has a patient-specific, non-generalizable answer; the second, with small “dose” differences has high risk of being a negative study; the third answer likely depends on local organisms, and equivalence studies require very large patient numbers.

Studies whose answers probably could change practice include: (1) Does adding Extracorporeal CO2 Removal (ECCO2R) to intubated ventilation in combined respiratory and metabolic acidosis improve survival/shorten ventilator time?, and (2) Does extracorporeal CPR (ECPR) for witnessed out-of-hospital cardiac arrest with a shockable rhythm save lives? Regarding the ECCO2R proposal, current practice involves hyperventilating high-dead-space patients, pressors, bicarbonate infusion, maybe dialysis, and outcomes are poor. ECCO2R can reduce ventilatory and alkalinizing/dialysis requirements¹. Regarding the ECPR proposal, current survival rates reported after 60 min of CPR without ECPR for possibly salvageable patients are 9%; with ECPR, 22%. Moreover, there are no clinical trials published².

The second criterion is important because if your site doesn't see enough patients, coordination with multiple centers and delay can imperil completion. Estimating sample size early for feasibility is important. For the ECCO2R proposal, an estimate for 30-day survival of such patients is 25%. To double survival to 50%, 2-sided p = 0.05, with 80% power, sample size is 65/group, 130 patients altogether. For the ECPR proposal, an estimate without ECPR is 5% survival after an hour of CPR. To raise survival to 25%, 2-sided p = 0.05, with 80% power, sample size is 58/group, 116 patients. These numbers may be practically achieved in some centers after 2-3 years, when the answers will still be pertinent.

The third criterion addresses whether the question is practical: Can a protocol fair to patients be devised and executed? For both ECCO2R and ECPR proposals, the protocols must (1) Establish criteria to assure no prolongation of life just to favor one unblinded group or another, and (2) Establish a process to assure uniform patient entrance and procedures among participating physicians and centers. Careful thought and collegial consultation at the start of study planning is important for helping ICU patients with your clinical research. Preparing the final study report similarly requires close attention and consultation³.

Introduction: The burnout phenomenon first came to clinical science 50 years ago. It is exponentially rising worldwide which prompted its discoverers to develop the most popular tool for its assessment, known as the Maslach burnout inventory (MBI)¹. Common symptoms of burnout include depression, irritability, and insomnia. It is known to hit professional areas where higher levels of stress are common. Intensive care unit (ICU) practitioners are particularly vulnerable to this condition. Bienvenu reported that up to 45% of ICU staff experienced burnout at a certain time in their career. The contributing factors include: age, gender, work schedule, involvement in decisions of withdrawing life support, policy of visiting hours, work quality, and care of dying patients. It is described as a growing crisis and is currently gaining a lot of interest aimed at addressing the issue and its consequences². We hypothesize that positive leadership with empowerment of staff may have an impact on burnout. Our objectives are to explore the prevalence of burnout in this area, to find the contributing factors, and determine the impact of the role of empowerment and leadership on burnout. Method: We conducted a cross-sectional descriptive study using a combined methodological quantitative and qualitative approach involving a convenience sample of 200 healthcare practitioners within surgical and medical ICUs of Hamad Medical Corporation (HMC), Qatar. We used two main instruments to develop an online questionnaire:

– The MBI-human service survey (MBI-HSS)¹ which is a standardized instrument to measure burnout. It utilizes 9 items related to emotional exhaustion and it is most frequently used in healthcare research. A score of 27 and more signals a high burnout level. – The Leadership scale, which assesses staff discernment of managers’ leadership attitude³. It is based on a 7-point Likert scale 11-item questionnaire that considers resolving conflicts with others, autonomy in decision-making, and staff involvement in development.

Conclusions: Everyone is at risk of burnout in the ICU setting. Implementing the empowerment hypothesis among the ICUs in Qatar could enhance the managerial preferences in the hospitals dealing with a wide spectrum of healthcare practitioners.

Empowerment is symbolized by energizing the practitioners⁵ and as the awareness of burnout is increasing, proper interventions should be directed at adequate orientation, early recognition, and dealing with the predisposing factors to prevent future occurrences. The findings of this study could widen the scope of practitioners who could be involved through education in diagnosing and managing burnout.

During their practice, intensivists are ought to face challenging cases that are rare. Intensivists need to be aware of the rare causes of shock beyond common presentations. In each category of shock, there are rare causes that require prompt identification and management. Certain clues in the patient's presentation might point to those rare causes.

Classically shock is classified into: distributive, hypovolemic, cardiogenic, and obstructive. In this era of bedside point-of-care ultrasound, intensivists are able to promptly identify the cause of shock and institute a resuscitation plan. However, there are cases when the diagnosis is still obscure and the cause of shock is not easily identified. For example, in a study of patients admitted with presumed septic shock, 7.4% had no identified cause of shock and 11% had sepsis mimickers.¹

Hypovolemic shock occurs secondary to a reduction in the effective circulating volume secondary to fluid loss or third spacing. A rare cause of hypovolemic shock is idiopathic capillary leak syndrome (Clarkson Syndrome).² The syndrome is characterized by recurrent episodes of rapidly progressive generalized edema, shock, renal failure and high hematocrit. The episode usually resolves in 3-7 days where the capillary leak resolves and a phase of pulmonary edema occurs. Several treatment options such as intravenous immunoglobulin (IVIG) and aminophylline were used in case reports.³

Vasodilatory shock occurs secondary to peripheral vasodilation and decrease in blood flow. It occurs as part of the systemic inflammatory response syndrome for which sepsis, acute pancreatitis, acute liver failure, and major trauma are common causes. Rare causes that need to be considered include: hemophagocytic lymphohistiocytosis (HLH), systemic mastocytosis, and toxic shock syndrome.

Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterized by macrophage activation and engulfment of hemopoetic cells which leads to pancytopenia. It is also characterized by cytokines storm that lead to a vasodilatory shock, multi-organ failure, and acute respiratory distress syndrome (ARDS). The most common triggers are infection, malignancy, and autoimmune diseases. Pointers to this diagnosis in the intensive care unit include: pancytopenias, hypofibrinogenemia, high triglycerides, and high ferritin. Treatment necessitates treating the underlying cause as well as using immune modifying therapies.⁴

Systemic mastocytosis is a rare cause of recurrent anaphylaxis shock. It results from the accumulation of mast cells in tissues and can present with anaphylaxis and vascular collapse. An important clue to the diagnosis is the presence of urticarial pigmentosa and the absence of an allergen history.⁵

Toxic shock syndrome is a unique cause of sepsis. It is caused by a pre-formed toxin produced by Staphylococcus aureus and Streptococcus pyrogenes. The clue to the diagnosis include the rapid onset after the precipitating factor, erythroderma, and skin desquamation. Treatment includes IVIG and Clindamycin.⁶

Background: One of the reasons to leave against medical advice (LAMA) from a hospital is to seek treatment in another hospital¹. Those patients are at high risk of readmission and mortality compared to patients with planned discharge². The aim of this study was to identify the factors for patients' presentations to an academic tertiary hospital Emergency Department (ED) specifically after LAMA from another hospital and to investigate the outcomes of these presentations. Methods: We conducted a prospective cross-sectional study. We included all patients who presented to Sultan Qaboos University Hospital (SQUH) ED after LAMA from other hospitals in Oman during the six-month study period. We excluded patients who died during hospitalization, those who refused to give consent, and those who were identified only after their ED visits' by reviewing the ED medical records' and were difficult to be contacted. We asked the participants to fill a paper-based questionnaire to investigate the factors of their presentations to SQUH ED. We designed the questionnaire by reviewing the literature on second opinion, patient's satisfaction, and LAMA^3–5. The questionnaire underwent a content validation by two experts. We investigated the outcomes of the presentations by reviewing the patients' medical charts. We used descriptive statistics to analyse the data. Results: A total of 112 patients presented to SQUH ED after LAMA from other hospitals. 94 of them participated, while 18 patients were excluded. There was equal male to female distribution among the participants and their mean age was 36.8 years (SD = 26.483). Figure 1 illustrates the previous hospitals where patients LAMA. The majority of patients (66.0%) were LAMA from governorate hospitals. Table 1 presents the factors of presentation to SQUH ED. The most common factor to present to SQUH ED (94.7%) was to get the quality of care delivered in SQUH. Out of 94 patients, 70 (74.5%) were admitted to SQUH. More than one-third of the admitted patients (35.7%) required management in critical care units. Conclusion: This study provides the factors that lead LAMA patients to choose an academic tertiary hospital for their second presentation. Identifying these factors can help the decision makers in the healthcare system in Oman to increase the quality of services in other healthcare facilities. Providing more healthcare facilities with diagnostic modalities like Magnetic Resonance Imaging (MRI) and in some places even Computed Tomography (CT) imaging may help decrease the incidence of LAMA. Also considering the addition of diagnostic and therapeutic units (for example: endoscopic suites and angiography suites) may allow for better health services in these hospitals and therefore minimize the occurrence of LAMA. Furthermore, allowing for and addressing the need for second opinion in some patients and organizing for that formally between different specialties in these hospitals may improve the patient satisfaction and therefore reduce the incidence of LAMA. Ultimately all the previously mentioned interventions can minimize the morbidity and mortality associated with LAMA. The study can also act as a pilot for larger multicentered studies.

Background: The provision of nutritional support among critically ill patients is complex and multifactorial.¹ There is a gap in the literature around the optimal amount of energy and protein critically ill patients require.² There has been a direct association with malnutrition and morbidity and mortality among critically ill patients.^3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients.³ Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.⁴ Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.⁵

Al-Adan Hospital in Kuwait caters for a population of 1.2 million, accounting for one third of the Kuwait's population. Clinical dietetics in the intensive care unit (ICU) at Al-Adan Hospital is an integral part of the multidisciplinary team and is deeply imbedded in the overall service. The dietetic model of care is proactive in nature and focuses on individualized patient care upon admission. Providing optimal nutritional support for critically ill patients extends beyond selecting the most appropriate formula and calculating caloric requirements. There has been a shift in the goals of care from “supportive nutrition” to “therapeutic nutrition”.⁵ The main objective of the dietetic service is to meet energy targets, preserve lean body mass, manage metabolic complications, and maintain patient immune function. Aim: This study will present recommendations for clinical practice and discuss outcomes associated with meeting nutritional targets. Methods: It is based on a literature review of existing guidelines, randomized controlled trials, and various meta-analyses examining the data available around nutrition in critically ill patients. Additionally, a description of a nutrition-focused model of care along with a retrospective analysis of routine data at Al-Adan Hospital ICU will be presented. Results: It is challenging to predict energy expenditure and energy requirements among critically ill patients. The current golden standard of care is indirect calorimetry however, its application among patients with altered gas exchange is debatable. Multiple studies have shown that there is a high rate of unintentional underfeeding among ICU patients due to feeding interruptions during procedures. In reviewing outcomes of 300 patients at Al-Adan Hospital, meeting the nutritional needs of patients throughout their ICU admission has shown to reduce the risk of infection and overall mortality (p ≤ 0.05) (See Table 1). Additionally, an association was observed between feeding intolerance and length of stay (p = 0.031). Conclusion: Observational data has demonstrated a positive association between meeting protein needs and survival. Applying a nutrition focused model of care within the ICU has clearly impacted on patient outcomes. Further research in the form of prospective randomized controlled trials exploring the optimal dose and time of nutritional therapy is necessary to examine nutritional needs of critical care patients.

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

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

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

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

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

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

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

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

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

Background: During the past two years, 5% of patients admitted to the Medical Intensive Care Unit (MICU) of Hamad General Hospital (HGH) had severe acute respiratory distress syndrome (ARDS) with a PaO2/FiO2 ratio less than 100 mmHg. The risks associated with this condition include ventilator associated lung injury, over distension of lungs, and poor gas exchange which results in increased morbidity and mortality. With quality improvement initiatives like prone positioning, the mortality and morbidity associated with severe acute respiratory syndrome¹ can be reduced by improving hypoxemia² with a significant enhancement in PaO2/FiO2 ratios while reducing injurious ventilation. Also, prone positioning can help prevent invasive interventions such as placing patients on extracorporeal membrane oxygenation (ECMO) therapy.³Methods: We evaluated the safety of prone positioning for improving hypoxemia in critically ill patients with PaO2/FiO2 ratio < 100 mmHg to PaO2/FiO2 ratio < 200 mmHg from 1^st January 2017 to 31^st December 2018, without major complications. Data collected included the PaO2/FiO2 ratios based on arterial blood gases of mechanically ventilated patients before and after prone positioning.

We were able to facilitate prone positioning in 72 out of 110 patients with severe ARDS having a total average PaO2/FiO2 ratio of 84.4 ± 30 mmHg. The patients were proned for a maximum of 16 hours in each session where up to three sessions were incorporated. No major complications were encountered during the proning sessions. This was thought to be accomplished through the coordination of a dedicated multidisciplinary team, education and simulation classes for physicians, nurses, and respiratory therapists, following appropriate inclusion and exclusion criteria for prone positioning, and implementing quality measures through Plan-Do-Study-Act (PDSA) cycles as represented in Figure 1. Results: The total average PaO2/FiO2 ratio before proning for 65% of patients (n = 72) with severe acute respiratory distress syndrome⁴ was 84.4 ± 30 mmHg and after one hour of 16 hours proning, it improved to 180.3 ± 78 mmHg. The remaining 35% of patients either had traumatic fractures, unstable spinal injury, severe hemodynamic instability, or morbid obesity together with ARDS which made them unfavorable for prone positioning. Out of those who were proned, 11 (12.5%) patients did not have improvement in oxygenation after proning due to non-recruitable lungs and were put on ECMO. The PaO2/FiO2 ratios before and after one hour of implementing the prone position technique in each quarter of 2017 and 2018 are represented in Figure 2. Conclusion: In patients with severe ARDS, prone positioning proves to be a safe practice and leads to improvement in hypoxemia without major complications. Our future prospects with respect to prone positioning include the following:

• Sustaining and standardizing the accomplished work of data collection. • Implementing the prone positioning technique across other critical care units of Hamad Medical Corporation. • Keeping a record of minor complications associated with prone positioning and resolving them in further sessions. • Documenting cases with contraindications to prone positioning.

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