Impact of new practice guideline to prevent catheter-related blood stream infection (CRBSI): experience at the Pediatric Intensive Care Unit of Phramongkutklao Hospital.

OBJECTIVE: To demonstrate the incidence of catheter-related blood stream infection (CRBSI) of patients in the pediatric intensive care unit (PICU) after implementing the new guideline to prevent CRBSI. METHODS: All patients who were admitted to PICU at Phramongkutklao Hospital between January and December 2006 and had central venous catheter (CVC) inserted from the operation room before admission or CVC placed in the PICU were included in a cohort study with longitudinal assessment of an overall catheter care policy targeted at the reduction of vascular access infection. The guideline included five key components (hand hygiene, maximal barrier precautions, povidine skin antiseptic, optimal catheter site selection, daily review of line necessity with prompt removal of unnecessary lines) called "central line bundle". All nursing staffs in the PICU were asked to attend an educational meeting in order to review the scientific data on vascular access insertion, device use and care. Data regarding age, underlying disease, location of insertion, duration, and complication were recorded. RESULTS: A total of 61 patients were recruited. Average duration of catheterization was 8.7 days. Complications were found in 8 cases (13.1%). Hematoma was the most common complication (6.6%) followed by infection (3.3%). Rate of CRBSI was reduced from 2.6 per 1000 catheter days to 2.4 per 1000 catheter days after implementing the new practice guideline. CONCLUSION: Rate of CRBSI was reduced after implementing the new "central line bundle" guideline to prevent CRBSI.

Late manifestation of congenital cystic adenomatoid malformation with lung abscess: a case report.

Congenital cystic adenomatoid malformation (CCAM) is a rare congenital cystic abnormality of the lung. Most of cases are usually diagnosed and managed in the newborn period even though some are asymptomatic and present in childhood or adult. The authors report a 7-year-old girl who presented with chronic cough, hemoptysis and clubbing of fingers. Physical examination revealed decreased breath sound and dullness on percussion at right upper chest. A chest radiograph showed a large thin-walled cyst with air fluid and a small thin-walled cyst occupied the whole right upper lobe. Computed tomography (CT) of the chest showed two large thin-walled cavities with air fluid level in the right upper lobe with few small cavities nearby. She was given antibiotics and cardiovascular and thoracic surgeon was consulted. The patient underwent right upper lobectomy. Microscopic examination was compatible with CCAM type 1. The post operative course was uneventful and the recovery was complete. She continued to be healthy at a follow-up visit about 8 months postoperatively but chest radiograph showed soft tissue density at right upper lung field. Chest CT findings were compatible with recurrent CCAM. A follow-up chest radiograph at 13 months postoperatively showed significant reduction in size of the lesion.

Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions.

PURPOSE: To compare the attitudes of physicians towards withholding and withdrawing life-sustaining treatments in intensive care units (ICUs) in low-middle-income Asian countries and regions with those in high-income ones, and to explore differences in the role of families and surrogates, legal risks, and financial considerations between these countries and regions. METHODS: Questionnaire study conducted in May-December 2012 on 847 physicians from 255 ICUs in 10 low-middle-income countries and regions according to the World Bank's classification, and 618 physicians from 211 ICUs in six high-income countries and regions. RESULTS: After we accounted for personal, ICU, and hospital characteristics on multivariable analyses using generalised linear mixed models, physicians from low-middle-income countries and regions were less likely to limit cardiopulmonary resuscitation, mechanical ventilation, vasopressors and inotropes, tracheostomy and haemodialysis than those from high-income countries and regions. They were more likely to involve families in end-of-life care discussions and to perceive legal risks with limitation of life-sustaining treatments and do-not-resuscitate orders. Nonetheless, they were also more likely to accede to families' requests to withdraw life-sustaining treatments in a patient with an otherwise reasonable chance of survival on financial grounds in a case scenario (adjusted odds ratio 5.05, 95 % confidence interval 2.69-9.51, P < 0.001). CONCLUSIONS: Significant differences in ICU physicians' self-reported practice of limiting life-sustaining treatments, the role of families and surrogates, perception of legal risks and financial considerations exist between low-middle-income and high-income Asian countries and regions.

Withholding and withdrawal of life-sustaining treatments in intensive care units in Asia.

IMPORTANCE: Little data exist on end-of-life care practices in intensive care units (ICUs) in Asia. OBJECTIVE: To describe physicians' attitudes toward withholding and withdrawal of life-sustaining treatments in end-of-life care and to evaluate factors associated with observed attitudes. DESIGN, SETTING, AND PARTICIPANTS: Self-administered structured and scenario-based survey conducted among 1465 physicians (response rate, 59.6%) who manage patients in ICUs (May-December 2012) at 466 ICUs (response rate, 59.4%) in 16 Asian countries and regions. RESULTS: For patients with no real chance of recovering a meaningful life, 1029 respondents (70.2%) reported almost always or often withholding whereas 303 (20.7%) reported almost always or often withdrawing life-sustaining treatments; 1092 respondents (74.5%) deemed withholding and withdrawal ethically different. The majority of respondents reported that vasopressors, hemodialysis, and antibiotics could usually be withheld or withdrawn in end-of-life care, but not enteral feeding, intravenous fluids, and oral suctioning. For severe hypoxic-ischemic encephalopathy after cardiac arrest, 1201 respondents (82.0% [range between countries, 48.4%-100%]) would implement do-not-resuscitate orders, but 788 (53.8% [range, 6.1%-87.2%]) would maintain mechanical ventilation and start antibiotics and vasopressors if indicated. On multivariable analysis, refusal to implement do-not-resuscitate orders was more likely with physicians who did not value families' or surrogates' requests (adjusted odds ratio [AOR], 1.67 [95% CI, 1.16-2.40]; P = .006), who were uncomfortable discussing end-of-life care (AOR, 2.38 [95% CI, 1.62-3.51]; P < .001), who perceived greater legal risk (AOR, 1.92 [95% CI, 1.26-2.94]; P = .002), and in low- to middle-income economies (AOR, 2.73 [95% CI, 1.56-4.76]; P < .001). Nonimplementation was less likely with physicians of Protestant (AOR, 0.36 [95% CI, 0.16-0.80]; P = .01) and Catholic (AOR, 0.22 [95% CI, 0.09-0.58]; P = .002) faiths, and when out-of-pocket health care expenditure increased (AOR, 0.98 per percentage of total health care expenditure [95% CI, 0.97-0.99]; P = .02). CONCLUSIONS AND RELEVANCE: Whereas physicians in ICUs in Asia reported that they often withheld but seldom withdrew life-sustaining treatments at the end of life, attitudes and practice varied widely across countries and regions. Multiple factors related to country or region, including economic, cultural, religious, and legal differences, as well as personal attitudes, were associated with these variations. Initiatives to improve end-of-life care in Asia must begin with a thorough understanding of these factors.

Situational analysis of palliative care education in thai medical schools.

OBJECTIVE: The Thai Medical School Palliative Care Network conducted this study to establish the current state of palliative care education in Thai medical schools. METHODS: A questionnaire survey was given to 2 groups that included final year medical students and instructors in 16 Thai medical schools. The questionnaire covered 4 areas related to palliative care education. RESULTS: An insufficient proportion of students (defined as fewer than 60%) learned nonpain symptoms control (50.0%), goal setting and care planning (39.0%), teamwork (38.7%), and pain management (32.7%). Both medical students and instructors reflected that palliative care education was important as it helps to improve quality of care and professional competence. The percentage of students confident to provide palliative care services under supervision of their senior, those able to provide services on their own, and those not confident to provide palliative care services were 57.3%, 33.3%, and 9.4%, respectively. CONCLUSIONS: The lack of knowledge in palliative care in students may lower their level of confidence to practice palliative care. In order to prepare students to achieve a basic level of competency in palliative care, each medical school has to carefully put palliative care content into the undergraduate curriculum.