Knowledge and Confidence of Final-Year Medical Students Regarding Critical Care Core-Concepts, a Comparison between Problem-Based Learning and a Traditional Curriculum.

BACKGROUND: Medical undergraduates should be prepared to recognize life threating critical conditions. Undergraduate medical curriculum development to incorporate more critical care education is an essential requirement. Problem Based Learning curriculum has a potential advantage in providing more focused critical care education to medical undergraduate. OBJECTIVES: We aimed to evaluate the final year medical students' knowledge and confidence in key critical care concepts in Problem Based Learning (PBL) curriculum compared to those in Traditional (Lecture) Based Learning curriculum. We also aimed to evaluate undergraduate's level of satisfaction with the exposure to critical care education during medical education and training. MATERIALS AND METHODS: This is a cross-sectional anonymous self-administered survey questionnaire completed by two groups of final-year medical students (PBL and TBL) from three Saudi medical schools to assess the degree of undergraduate exposure to critical care and their knowledge of key critical care assessment parameters. RESULTS: The responses of 279 final year medical students was analyzed (70% response rate). The majority (53%) was male and the mean age 23.9 ± 1.4 years. Only 13% of students felt confident to manage hypovolemic shock and 15% could recognize the signs of a threatened airway. One third of the students (29%) correctly identified the critical level of lactic acid in shock and less than 2% of the sample responded correctly to all the questions related to the formal assessment of critically ill patients. Lectures were the main source of information in acute care. More than two-thirds (46%) of the sample indicated that they received tuition in critical care, however the total duration spent in a critical care rotation or teaching was 1 day or less. The medical students, who completed their training with a Problem-Based Learning curriculum, had a higher knowledge base and were more confident in many critical care concepts. Only 6.5% choose critical care as their likely future career. CONCLUSION: Medical undergraduates in PBL have an overall better knowledge on key concepts and assessment tools applicable to evaluating and managing critically ill patients compared to students in TBL. However the gap in knowledge and confidence in assessing ill patients in both groups is evident. Critical care was not chosen as a preferred future career in all surveyed students. There is a need for institutional support and endorsement of undergraduate critical care exposure and education in Saudi Universities both to better prepare medical students for their imminent post-graduates exposure to ill patients and to help in closing the gap in critical care physicians through promoting the specialty.

Use of ultrasound guidance in central venous catheter placement by emergency physicians in Saudi Arabia.

OBJECTIVES: To determine the ultrasound guidance for central venous catheter (USG-CVC) placement rate of emergency physicians (EPs) in Kingdom of Saudi Arabia. METHODS: A cross-sectional survey study regarding the respondents' demographic profiles, formal and informal training in USG-CVC placement, experiences, and attitudes towards the procedure was emailed to all EPs registered with the Saudi Commission for Health Specialties (SCFHS) between October and December 2018. RESULTS: In total, 234/350 SCFHS-registered EPs completed the survey; the response rate was 66.9%. Most respondents (70.5%) were board-certified in emergency medicine (EM). Ninety percent indicated that US device for CVC placement assistance was available. Most EPs (78.2%) had performed USG-CVC placement; the US usage rate correlated significantly with recent graduation from residency (p=0.048). In total, 83.3% received formal training during residency. Of the 234 respondents, 53.8% felt extremely comfortable with CVC placement with USG and 19.7% without USG (p less than 0.01). Nevertheless, most respondents desired further USG-CVC training. CONCLUSION: Despite existing evidence and a consensus on its superiority over the landmark technique, USG-CVC placement has not been adopted by a small proportion of EPs into clinical practice. Formal training, education, and institutional provision of permanent onsite US machines may address any barriers.

Clinical review: percutaneous dilatational tracheostomy.

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.

Successful use of non-invasive positive pressure ventilation in a complicated flail chest.

The current advanced trauma life support manual states that patients with significant hypoxia namely, SaO2 <90% on room air as a result of pulmonary contusion should be intubated and ventilated within the first hour of injury. Recently, several researchers have shown improved outcomes when patients with acute respiratory failure are managed with non-invasive positive pressure ventilation NIPPV. Trauma patients may also benefit from this therapy. We report a case of 15-year-old boy with isolated flail chest and pulmonary contusion, who was intubated in the emergency room, and was managed successfully with the NIPPV in the intensive care unit ICU despite, having had aspiration pneumonia early in the course of his stay. After initial stabilization, he failed a spontaneous breathing trial. Due to absence of contraindications to the use of NIPPV, the patient was extubated on day 7 from pressure support ventilation of 15 cmH2O and positive end expiratory pressure of 8 cmH2O to immediate NIPPV use. Three days later after a total of 50 hours of NIPPV use in the ICU the patient was successfully discharged home.

Protocol-driven vs. physician-driven electrolyte replacement in adult critically ill patients.

BACKGROUND: The intensive care unit is a dynamic environment, where high numbers of patients cared for by health care workers of different experiences and backgrounds might result in great variability in patient care. Protocol-driven interventions may facilitate timely and uniform care of common problems, like electrolyte disturbances. We prospectively compared protocol-driven (PRD) vs. physician-driven (PHD) electrolyte replacement in adult critically ill patients. PATIENTS AND METHODS: In the first month of the two-month study, potassium, magnesium, and phosphate levels were checked by a physician before ordering replacement (PHD replacement period). Over the second month, ICU nurses proceeded with replacement according to the protocol (PRD replacement period). We collected demographic data, admission diagnosis, number of potassium, magnesium, and phosphate levels done per day, number of low levels per day, number of replacements per day, time between availability of results to ordering replacement, time to starting replacement, post-replacement levels, serum creatinine, replacement dose, arrhythmias and replacement route. RESULTS: During the PHD replacement period, 43 patients meeting the inclusion criteria were admitted to the ICU, while 44 were admitted during the PRD month. The mean time (minutes) from identifying results to replacement of potassium, phosphate and magnesium was significantly longer with PHD replacement compared with PRD replacement (161, 187, and 189 minutes vs. 19, 26, and 19 minutes) (P<0.0001). The number of replacements needed and not given was also significantly lower in the PRD replacement period compared with the PHD replacement period (2, 4, and 0 compared with 9, 6 and 0) (P<0.05). No patients had high post-replacement serum concentrations of potassium, phosphate or magnesium. CONCLUSIONS: This study shows that a protocol-driven replacement strategy for potassium, magnesium and phosphate is more efficient and as safe as a physician-driven replacement strategy.

Therapy for ventilator-associated pneumonia: what works, what doesn't.

Ventilator-associated pneumonia is a common cause of morbidity and mortality in critically ill patients. Inappropriate initial antimicrobial therapy is associated with poor outcome. An initial aggressive strategy using broad-spectrum antibiotics based on the local distribution of pathogens, patient risk factors, and antimicrobial characteristics; followed by focused therapy based on microbiologic studies, will help minimize the chance of inappropriate therapy and the emergence of resistance.

Experience with 224 percutaneous dilatational tracheostomies at an adult intensive care unit in Bahrain: a descriptive study.

UNLABELLED: Tracheostomy is one of the most commonly performed procedures in critically ill patients. Over the past 15 years, many large university hospitals have reported their experience with percutaneous dilatational tracheostomy (PDT). We have described and compared our experience with 224 PDTs that we performed in the last four and a half years. We have also compared PDT performed with and without bronchoscopic guidance at our setting and PDT verses surgical tracheostomy. OBJECTIVE: The purposes of this study are to evaluate the safety of PDT in our hospital setting and to compare our results with those published in the literature. DESIGN: A retrospective study for our experiences about safety and efficacy of 224 PDTs in an intensive care unit (ICU) setting. SETTING: A 11-bedded adult medical, surgical, neuro-trauma ICU at Salmaniya Medical Complex, Bahrain. MATERIALS AND METHODS: This is based on our experiences about complications/timings of all PDTs performed from October 2002 to February 2007. A retrospective chart analysis. RESULTS: There were 15 mechanical complications in total, including nine patients developing bleeding during or post-procedure, three patients developing pneumothorax and two patients developing cellulitis; in one procedure, a tracheostomy tube was misplaced. The proportion of total complications was 6.6% and no death. CONCLUSIONS: From our experience, bronchoscope can be used during PDTs performed in ICU by inexperienced intensivists who do not have good exposure to procedures, but after gaining adequate experience, PDT can be performed safely without using bronchoscope.

Pulmonary hydatid cyst in a pregnant patient causing acute respiratory failure.

A 21-year-old primigravida, at 32 weeks of gestation, presented with acute onset of respiratory failure and circulatory shock. Chest imaging showed findings suggestive of ruptured hydatid cyst, which was confirmed by histology post-thoracotomy. Tissue cultures from the removed cyst grew Mycobacterium tuberculosis also. She was successfully managed in the intensive care unit and was then discharged home on antituberculosis medications in addition to albendazole after prolonged hospitalization and a need for chest tube for bronchopleural fistula. Acute respiratory failure and anaphylactic shock secondary to ruptured pulmonary hydatid cyst and superimposed pulmonary tuberculosis in a pregnant lady should be considered in patients living in endemic areas.

Use of noninvasive positive pressure ventilation during pregnancy: case series.

Mechanical ventilation is commonly required in critically ill pregnant patients, requiring ICU admission, with higher morbidity and mortality related to airway management. Alternatively, noninvasive positive pressure ventilation (NIPPV) is increasingly used to treat nonpregnant patients. Pregnancy has been a contraindication to its use. We would like to report a case series of successful use of NIPPV in pregnancy.NIPPV is increasingly used to treat hypoxemic respiratory failure. It has rarely been used during pregnancy. On the other hand, acute respiratory failure (ARF) remains a leading cause of ICU admission in obstetric patients. The use of NIPPV in managing ARF in pregnant patients was not investigated. We report the outcome of treatment with NIPPV of four sickle cell disease pregnant patients with ARF caused by acute chest syndrome. Median APACHE II score for the four cases was 27. Intubation was avoided in all cases. None had aspiration. Mean duration of NIPPV was 40 h with ICU discharge after a mean of 4 days.