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

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.