Development of an emergency airway response system for COVID-19 at a tertiary care hospital in resource limited country.

The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.

Disparities in adult critical care resources across Pakistan: findings from a national survey and assessment using a novel scoring system.

BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.

Outcome of patients with acute pancreatitis requiring intensive care admission: A retrospective study from a tertiary care center of Pakistan.

BACKGROUND AND OBJECTIVE: Acute pancreatitis (AP) is an inflammatory disease. Patients presenting with severe disease may require intensive care unit (ICU) admission. Factors predicting mortality and morbidity need to be identified for improving outcome. The objective of this study was to see the outcome of these patient presented to single center over a period of ten years. The secondary objective was to identify the factors responsible for adverse outcome. METHODS: The medical records of adult patients from year 2006 to 2016 requiring ICU admission for AP were reviewed retrospectively. The data was collected on the predesigned Performa for patient's demographic, etiology, severity of disease and reason of ICU referral. Besides this physiological and biochemical parameters at time of arrival in ICU were also recorded. Management aspects related to disease course including the ICU related complications were also recorded. The outcome was predicted on the basis of mortality and length of stay (LOS) in ICU and hospital. RESULTS: Total 85 patients were identified of having AP requiring ICU admission. 56% of these cases were referred from emergency. Mean Ranson score (RS) was 2.6 and 2.7, at and after 48 hours of admission. Necrosis was present in 48% of cases. Mean APACHE-II score was 23. Sepsis was the commonest complication in ICU. The median LOS in ICU and hospital was six and 12 days respectively. The overall hospital mortality was 52%, out of which 82% died in ICU. RS at admission and APACHE were correlated well with outcome. Similarly associations of factors like need of vasopressors, ARDS, pneumonia, sepsis and AKI requiring intervention were also related to mortality. Likewise development of necrosis or intra-abdominal hypertension showed increased mortality. Biochemical parameters serum blood urea nitrogen (BUN), PH and serum glutamic-oxaloacetic transaminase were also directly linked to adverse outcome. CONCLUSION: AP patients requiring ICU admission represent severe form of disease. There is a need to develop protocol based care, which should be started immediately after hospital admission. This should have special focus on fluid resuscitation and nutritional therapy. Role of simple bed site parameters like BUN needs to be evaluated.

Multi-Organ Dysfunction Secondary To Yellow Scorpion Sting.

Scorpion stings are common in tropical and subtropical regions. The history and clinical manifestation warrant urgent recognition and treatment. The incidence of scorpion stings in Pakistan is not known as there is no published data available in literature. We report our experience of a yellow scorpion sting victim who required intensive care admission after developing multi-organ dysfunction.

The role of inhaled nitric oxide beyond ARDS.

Patients with traumatic brain injury complicated by acute respiratory distress syndrome (ARDS) are not uncommon in intensive care unit (ICU). The ventilatory management of patients combined with both of these catastrophic conditions is not straightforward. Evidence-based permissive hypercapnia strategy for ARDS could be fatal in patients with intracranial hypertension. Adjunctive use of inhaled nitric oxide (INO) is well-defined as a rescue therapy in severe ARDS, but its specific role in intracranial hypertension is somewhat uncertain. We report a case, which following traumatic brain injury developed both intracranial hypertension and ARDS. INO was given for ARDS, but coincidentally it also improved the raised intracranial pressure (ICP) and patient's neurological outcome. The case report will be followed by literature review on the role of INO in raised ICP.

Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review.

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines. Aim of Study: The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality. Materials and Methods: Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male. Results: In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ2(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR). Conclusions: In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO's best approach for this population.

In-hospital cardiac arrest in middle-income settings: A comprehensive analysis of clinical profiles and outcomes of both adults and pediatrics.

Background: In hospital cardiac arrest is associated with poor survival despite basic and advanced life support measures. This study aimed to identify the clinical characteristics and outcomes of cardiac arrests occurring during in-hospital admission to the tertiary care center in Pakistan. Method: A retrospective, cross-sectional study at Aga Khan University Hospital from 2021 to 2023 analyzed 230 cardiac arrest cases. Data included demographics, arrest type, timing, initial rhythm, resuscitation duration, and arrest location. American Heart Association guidelines were adhered to for life support. The main outcomes focused on the return of spontaneous circulation survival to hospital discharge. Results: During the study, 230 cardiac arrests were observed: 152 in adults (mean age 57.8, 142 shockable cases, ROSC 52.6 %, alive at discharge 28.3 %) and 78 in pediatric patients (mean age 4.99, non-shockable rhythm 85.9 %, ROSC 51.3 %, alive at discharge 17.9 %). Adult Charles comorbidity index: 2.88 (SD±2.08), pediatric index: 0.610 (SD±0.88). Survival rates were lower with a high comorbidity index and code duration > 20 min. Conclusion: The study provides valuable observational data that challenges global survival rates for in-hospital cardiac arrest. It highlights how factors like being in monitored units and the presence of rapid response teams can lead to higher survival rates. The research underscores the influence of comorbidities, initial rhythms, and the duration of resuscitation efforts on patient outcomes, emphasizing the need for more research, especially in settings with limited resources.

Risk factors for mortality in hospitalized COVID-19 patients across five waves in Pakistan.

This retrospective cohort study aims to describe the clinical characteristics and outcomes and assess risk factors for mortality across the epidemic waves in hospitalized COVID-19 patients in a major tertiary-care center in Pakistan. A total of 5368 patients with COVID-19, hospitalized between March 2020 and April 2022 were included. The median age was 58 years (IQR: 44-69), 41% were females, and the overall mortality was 12%. Comparative analysis of COVID-19 waves showed that the proportion of patients aged ≥ 60 years was highest during the post-wave 4 period (61.4%) and Wave 4 (Delta) (50%) (p < 0.001). Male predominance decreased from 65.2% in Wave 2 to 44.2% in Wave 5 (Omicron) (p < 0.001). Mortality rate was lowest at 9.4% in wave 5 and highest at 21.6% in the post-wave 4 period (p = 0.041). In multivariable analysis for risk factors of mortality, acute respiratory distress syndrome (ARDS) was most strongly associated with mortality (aOR 22.98, 95% CI 15.28-34.55, p < 0.001), followed by need for mechanical ventilation (aOR 6.81, 95% CI 5.13-9.05, p < 0.001). Other significant risk factors included acute kidney injury (aOR 3.05, 95% CI 2.38-3.91, p < 0.001), stroke (aOR 2.40, 95% CI 1.26-4.60, p = 0.008), pulmonary embolism (OR 2.07, 95% CI 1.28-3.35, p = 0.003), and age ≥ 60 years (aOR 2.45, 95% CI 1.95-3.09, p < 0.001). Enoxaparin use was associated with lower mortality odds (aOR 0.45, 95% CI 0.35-0.60, p < 0.001. Patients hospitalized during Wave 4 (aOR 2.22, 95% CI 1.39-3.56, p < 0.001) and the post-wave 4 period (aOR 2.82, 95% CI 1.37-5.80, p = 0.005) had higher mortality odds compared to other waves. The study identifies higher mortality risk in patients admitted in Delta wave and post-wave, aged ≥ 60 years, and with respiratory and renal complications, and lower risk with anticoagulation during COVID-19 waves.

Risk factors and outcomes in patients with severe Necrotizing fasciitis admitted to surgical intensive Care unit: a retrospective cohort study from pakistan.

Background: Necrotizing fasciitis (NF) is a debilitating condition that has high mortality and morbidity even in specialized centres. This study aims to determine risk factors in our local population and identify variables that contribute to mortality in the necrotizing fasciitis patients treated in the surgical intensive care unit of a tertiary care hospital. Methods: This retrospective cross-sectional study included 39 patients admitted to the surgical ICU from January 1, 2015 to June 30, 2019. They were analyzed for comorbidities, symptoms at presentation, predisposing factors, location of the infection, microbiological analysis and mortality. Results: There were 27 (69.2%) males and 12 (30.8%) females while the age was distributed as 47.44±15 years. Pain was the most frequently reported symptom (89.7%), followed by swelling (79.5%) and tenderness (77%). Significant predisposing factors included trauma in 14 (35.9%) and Intramuscular injections (IM) in 10 (25.6%) patients. On univariate and multiple logistic regression, patients with chronic kidney disease (AOR:1.27, 95% CI: 0-691.22) and ischemic heart (AOR: 1.55, 95% CI: 0.02-153.26) disease had higher odds of mortality than those with no comorbidity. The overall mortality was 12/39 (30.8%). Conclusion: Intramuscular injections without aseptic measures in our local population are a significant predisposing risk factor for severe necrotizing fasciitis. High laboratory risk Indicators for necrotizing fasciitis and acute physiology and chronic health evaluation II scores at admission were associated with increased mortality.

Ease of Intubation with McGrath Videolaryngoscope and Incidence of Adverse Events During Tracheal Intubation in COVID-19 Patients: A Prospective Observational Study.

Background: Tracheal intubation in critically ill patients remains high-risk despite advances in equipment, technique, and clinical guidelines. Many patients with COVID-19 were in respiratory distress and required intubation that is considered an aerosol-generating procedure (AGP). The transition to videolaryngoscopy as a routine first line option throughout anesthetic and ICU practice has been reported. We evaluated the ease of intubation, success rate, use of accessory maneuvers and adverse outcomes during and 24 hours after intubation with the McGrath videolaryngoscope. Methods: This was a prospective, observational single center study conducted at non-operating room locations that included all adults (>18 years old) with suspected or confirmed COVID-19 infection and were intubated by McGrath videolaryngoscope. The anesthesiologist performed tracheal intubation were requested to fill online data collection form. A co-investigator was responsible to coordinate daily with assigned consultants for COVID intubation and follow up of patients at 24 hours after intubation. Results: A total of 105 patients were included in our study. Patients were predominantly male (n=78; 74.3%), their COVID status was either confirmed (n=97, 92.4%) or suspected (n=8, 7.6%). Most were intubated in the COVID ward (n=59, 56.2%) or COVID ICU (n=23, 21.9%). The overall success rate of intubation with McGrath in the first attempt was 82.9%. The glottic view was either full (n=85, 80.95%), partial (n=16, 15.24%) or none (n=4, 3.81%). During intubation, hypoxemia occurred in 18.1% and hypotension in 16.2% patients. Within 24 hours of intubation, pneumothorax occurred in 1.9%, cardiac arrest and return of spontaneous circulation in 6.7% and mortality in 13.3% of patients. Conclusion: These results illustrate the ease and utility of the McGrath videolaryngoscope for tracheal intubation in COVID-19 patients. Its disposable blade is of significant value in protectin during tracheal intubation.

Improving Postgraduate Anaesthesiology Training in a Low-Middle Income Country by Embracing the New Trends in Medical Education.

Postgraduate medical training has increasingly adapted to competency-based medical education (CBME). In an endeavour to stay abreast with the new trends in medical education and adapt to CBME frameworks, an in-depth review and revision of the Anaesthesiology training curriculum were conducted. The authors worked on the task from December 2020 to December 2021. Learning outcomes were defined and corresponding competencies were identified and relevant teaching, learning and assessment strategies were aligned with each learning outcome. Additionally, lists were devised for topics to be covered through didactic lectures and simulation-based workshops. The revised curriculum is currently being implemented in a phased manner. Formative workplace-based assessment tools are being introduced to complement CBME. Moreover, daily clinical assessments, entrustable professional activity (EPA), simulation-based workshops and assessments have been introduced. Key Words: Anaesthesiology, Postgraduate training, Curriculum revision, Competency-based medical education, Low-middle income country, Simulation-based training.

Evaluating the impact of digitalization, renewable energy use, and technological innovation on load capacity factor in G8 nations.

Ecosystems are in danger due to human-caused air, water, and soil pollution, so it is important to find the underlying causes of this issue and develop practical solutions. This study adds to environmental research gap by suggesting the load capability factor (LCF) and using it to look at the factors affectting environmental health. The load capacity factor simplifies monitoring environmental health by illustrating the distinction between ecological footprint and biocapacity. We examine the interplay between mobile phone users (Digitalization DIG), technological advancements (TEC), renewable energy use, economic growth, and financial development. This study assesses G8 economies' data from 1990 to 2018, using a Cross-Section Improved Autoregressive Distributed Lag CS-ARDL estimator and a cointegration test. The data shows that green energy, TEC innovation, and DIG are all beneficial for natural health. Based on the results of this study, the G8 governments should focus on environmental policies that promote economic growth, increase the use of renewable energy sources, guide technological progress in key areas, and encourage the development of digital information and communications technologies that are better for the environment.

Environmental variables influence the developmental stages of the citrus leafminer, infestation level and mined leaves physiological response of Kinnow mandarin.

Climate change has not only exacerbated abiotic stress, but has also rendered external conditions more feasible for pests to spread and infest citrus fruit. Citrus leafminer (Phyllocnistis citrella) is a potential pest that directly feeds the newly sprouted leaves and twigs of all three spring, summer and autumn flushes. Increasing temperatures in spring and autumn, leafminer accrued more heat units or developmental degree days to accelerate the biological stages of its life-cycle, thereby increasing the pressure of infestation. Present work was conducted at three different environmental conditions in Sargodha, Toba Tek Singh (TTS) and Vehari districts of the Punjab province, Pakistan; all three experimental sites were located in different agro-ecological zones. More infestation was recorded in all three flushes at TTS and Vehari than in Sargodha. Overall, more damage was observed due to higher temperatures in TTS and Vehari than in Sargodha. After May-June heat stress, spontaneous vegetative growth continued from July to November, produced newly spouted tender leaves for feeding the leafminer larvae, and was seen more in TTS and Vehari. Leafminer larva prefers to enter young and tender leaves with a maximum entrance in leaves up to 1 cm2 in size while observing no entrance above 3 cm2 of leaf size. Physiological response of leaves primarily attributed to chlorophyll and carotenoid contents, both of which were recorded lower in the mined leaves, thereby reducing leaf photosynthetic activity. Similarly, lower levels of polyphenols and antioxidant activity were also recorded in the mined leaves. The on-tree age of mined leaves of three vegetative flushes of Kinnow plant was also less counted than non-mined leaves. Climate change has affected vegetative phenology and become feasible for pests due to extemporaneous leaf growth, particularly leafminer, and eventually causes economic loss by supplying low carbohydrates either to hanging fruits or next-season crops.

Incidence and risk factors of delirium in surgical intensive care unit.

BACKGROUND: To evaluate the incidence and modifiable risk factors of delirium in surgical intensive care unit (SICU) of tertiary care hospital in a low-income and middle-income country. METHODS: We conducted a single cohort observational study in patients over 18 years of age who were admitted to the SICU for >24 hours in Aga Khan University Hospital from January to December 2016. Patients who had pre-existing cognitive dysfunction were excluded. Intensive Care Delirium Screening Checklist was used to assess delirium. 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 and body mass index was 26.25±3.57 kg/m2. Delirium was observed in 19 of 87 patients with an incidence rate of 21.8%. Multivariable analysis showed chronic obstructive pulmonary disease, pain score >4 and hypernatremia were strong predictors of delirium. Midazolam (adjusted OR (aOR)=7.37; 95% CI 2.04 to 26.61) and propofol exposure (aOR=7.02; 95% CI 1.92 to 25.76) were the strongest independent predictors of delirium while analgesic exposures were not statistically significant to predict delirium in multivariable analysis. CONCLUSION: Delirium is a significant risk factor of poor outcome in SICU. There was an independent association between pain, sedation, COPD, hypernatremia and fever in developing delirium. LEVEL OF EVIDENCE: IV.

Climate variables effect on fruiting pattern of Kinnow mandarin (Citrus nobilis Lour × C. deliciosa Tenora) grown at different agro-climatic regions.

Kinnow orchards grown in different agro-ecological regions of Punjab, Pakistan, namely Sargodha, Toba Tek Singh (TTS) and Vehari districts, were selected to assess the effect of climate variables on fruit-bearing patterns. Experiment was laid out in RCBD while selecting identical features Kinnow plants and labeled twigs at analogous canopy positions in all three sites. Temperature was reported higher in TTS and Vehari areas, while relative humidity in Sargodha accounted for different levels of agrometeorological indices by computing more variations in warm districts. Climate variables influenced fruit-bearing habits and vegetative growth trend in all three flushes while recording heavy fruit-bearing plants during on-year and light fruit-bearing in off-year at Vehari. Similarly, three vegetative flushes were recorded unevenly in all three sites due to different fruit-bearing patterns induced by climate variables. Harvesting pattern of orchards began earlier in Sargodha, where maximum orchards were harvested before new flowering to add evenness to fruiting habits during on & off-years. In warm conditions, fruit ripening arrived in the peak of winter and mostly domestic market-driven harvesting resulted in late start of fruit picking with more erratic fruit-bearing habits. Both physiological and pathological fruit drops have been significantly affected by climate variables with a higher degree of physiological drop in warm regions and pathological effects in the humid conditions of Sargodha on heavy fruit-bearing plants. Fruit yield and grading quality were also affected in both seasons by showing more asymmetrical trend in yield and fruit grading in warm areas of TTS and Vehari due to an irregular fruiting pattern compared to Sargodha. From now on, the climate variables of the three sites directly influenced the fruiting patterns, vegetative flushes, fruit drops, yields and grades of Kinnow mandarin.

Nephroureterostomy as a treatment of obstructive uropathy: A single center experience.

OBJECTIVE: To report the outcomes of percutaneous nephroureterostomies performed in a single center a period of ten years. MATERIALS AND METHODS: We retrospectively collected and analyzed data for 52 nephroureterostomy procedures that were performed from September 2008 to August 2018. We present patient's demographics, indications for the procedure, type of anesthesia, technical difficulties, length of stay in hospital and complications. RESULTS: A total of 52 procedures including 13 bilateral nephroureterostomies were performed on 39 patients. Taking into account the need for replacement of nephroureterostomy procedures during the study period, total number of procedures was 168. Out of a total 39 patients, 32 (84%) of patients had advanced cancer. All procedures were performed as day cases using sedation and had no immediate or early complications. Ten patients or 16% (27 nephroureterostomies out of total 168 procedures) had minor complications. CONCLUSIONS: To the best of author's knowledge, this is the largest case series reporting the outcome of percutaneous nephroureterostomies. We can therefore conclude that percutaneous nephroureterostomy is a useful palliative procedure to relieve ureteric obstruction, when other measures are not possible, and it has low incidence of complications. However, further studies are warranted to compare different procedures used to relieve ureteric obstruction.

Cobalt-related cardiomyopathy: A real concern! A review of published evidence.

BACKGROUND: Cobalt (Co) toxicity-related cardiomyopathy (CMP) in hip arthroplasty has recently been reported in the literature. The purpose of this review was to identify and assess available published evidence of CMP in hip arthroplasty patients and to derive recommendations for management. METHODS: We evaluated 23 cases reported till October 2018 and stratified into three categories, based on pre-existing risk factors for CMP, histological confirmation and evidence of systemic signs of Co toxicity. RESULTS: Co toxicity was considered to be the definite cause of CMP in 8 cases and probably contributory in 13 cases. Two cases were considered to have developed CMP secondary to pre-existing risk factors. Majority of the patients had good recovery of cardiac function after hip revision and cardiac management, but five cases deteriorated and died. CONCLUSION: Although Co-related CMP has been reported in a small number of cases of hip arthroplasty, a delay or missed diagnosis may lead to significant morbidity and mortality. Timely diagnosis, removal of causative implant and avoidance of metal articulations in revision for fractured ceramic implants may help in effective management.

Attitudes and knowledge of anesthesiology trainees to radiation exposure in a Tertiary care hospital.

BACKGROUND AND AIMS: Ionizing radiation procedures are indispensable in medical clinical practice. Exposure to radiation at any dose could have serious adverse effects. Anesthesiologists working in interventional radiology suites are at a higher risk of radiation exposure than other personnel. The aim of this study was to assess the knowledge and attitude of anesthesiology trainees towards the radiation hazards and current safety practices. METHODS: This prospective cross-sectional survey was conducted at the department of anesthesiology at Aga Khan University. All anesthesiology trainees working in the department were given a 12-question paper-based survey after getting ethical review committee approval and informed consent. The questionnaire contained requests for personal demographic data and specific questions regarding radiation protection. RESULTS: A total of 54 participants were included in this survey. Thirty-two (59.3%) were male, and 22 (40.7%) were female. The average year of experience working in anesthesia of the participants was 2.8 ± 1.65 years (range, one to eight years). Frequency of radiation exposure of 32 (59.3%) participants was 1-5 times per week. Approximately 68.5% (37/54) of participants believed they took adequate precautions for protection against radiation. Only 20.4% (11/54) used both a lead apron and a thyroid shield for prevention of radiation exposure. Most participants using the radiation shield or clothing (70.4%; 38/54) cited concerns about cancer. CONCLUSIONS: A lack of knowledge persists among anesthesiology trainees in our institute regarding the risks associated with ionizing radiation. This study also serves to highlight the need for anesthesiology trainees to protect themselves properly. Radiation dose, hazards, and protection strategies must be included in the basic curriculum of medical colleges.

Randomised controlled trial to assess the effectiveness of apnoeic oxygenation in adults using low-flow or high-flow nasal cannula with head side elevation versus usual care to prevent desaturation during endotracheal intubation in the emergency department (ApOxED): study protocol.

INTRODUCTION: Apnoeic oxygenation is a process of delivering continuous oxygen through nasal cannula during direct laryngoscopy. The oxygen that is delivered through these nasal cannulas is either low flow or high flow. Although the effectiveness of apnoeic oxygenation has been shown through systematic reviews and randomised controlled trials, a comparison of high-flow versus low-flow oxygen delivery has not been tested through a superiority study design. In this study we propose to assess the effectiveness of giving low-flow oxygen with head side elevation versus high-flow oxygen with head side elevation against the usual practice of care in which no oxygen is provided during direct laryngoscopy. METHODS AND ANALYSIS: This will be a three-arm study instituting a block randomisation technique with a sample size of 46 in each arm (see table 1). Due to the nature of the intervention, no blinding will be introduced. The primary outcomes will be lowest non-invasive oxygen saturation measurement during direct laryngoscopy and during the 2 min after the placement of the tube and the first pass success rate. The intervention constitutes head side elevation up to 30° for improving glottis visualisation together with low-flow or high-flow oxygen delivery through nasal cannula to increase safe apnoea time for participants undergoing endotracheal intubation. Primary analysis will be intention to treat. ETHICS AND DISSEMINATION: The study is approved by the Ethical Review Committee of Aga Khan University Hospital (2019-0726-2463). The project is an institution University Research Committee grant recipient 192 002ER-PK. The results of the study will be disseminated among participants, patient communities and healthcare professionals in the institution through seminars, presentations and emails. Further, the findings will be published in a highly accessed peer-reviewed medical journal and will be presented at both national and international conferences. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT04242537).

An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes.

BACKGROUND: Antibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC. METHOD: We conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September-December 2017) and post-ASP data (April-July 2018). January-March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness. RESULT: 123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly. CONCLUSION: ASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.