Identifying the barriers and facilitators to implementation of ventilator bundle in the nepalese intensive care unit: A descriptive qualitative study.

BACKGROUND: A ventilator bundle is an effective preventive strategy against the development of ventilator-associated pneumonia (VAP). However, in clinical practice ventilator bundle implementation is poor. Understanding the barriers to ventilator bundle implementation in low- and middle-income countries can inform the development of effective implementation strategies to reduce the burden of VAP. OBJECTIVES: The primary objective of this study was to explore the barriers and facilitators of ventilator bundle implementation perceived by healthcare professionals (HCPs) working in intensive care units (ICU) in Nepal. The secondary objective was to prioritise the barriers when developing implementation strategies. METHODS: This study used a pragmatic approach comprising a series of methods to identify the implementation strategies: (i) Barriers and facilitators were explored using a qualitative study design. Twenty-one HCPs selected using the maximum variation sampling technique from a large tertiary hospital, completed semistructured interviews. All the interviews were recorded, transcribed word-by-word, and uploaded into NVivo for analysis using the thematic analysis approach. (ii) After analysis, nine participants were selecteded to determine the priority order of the barriers using a barrier identification and mitigation tool. RESULTS: The data analysis revealed five main themes and 19 subthemes that affected ventilator bundle implementation. The main themes were provider-related factors, organisational and practice-related factors, performances of work, environmental conditions, and patient-related factors. The common barriers were job insecurity, poor knowledge, negative attitude, insufficient equipment, and severity of patient disease. Common facilitators were educational training, equipment functioning, adequate staff, strong leadership, and organisational support. Finally, eight main barriers were prioritised to target the change. CONCLUSION: The barriers to implementing ventilator bundles in ICUs were identified. Focussing on addressing the prioritised barriers may aid in improving patient care and safety in ICUs. Results may guide HCPs in the development of implementation strategies to reduce the burden of VAP.

Evaluating Antibiotic Treatment Guideline Adherence to Ongoing Antibiotic Stewardship in a Tertiary Care Setting: A Retrospective Observational Study.

Antimicrobial resistance (AMR) is widely regarded as an increasing threat to global public health. Antibiotic treatment guidelines have been increasingly recognized as an effective tool to guide appropriate prescriptions and help curtail antibiotic resistance. The present study aimed to assess physician's adherence to hospital antibiotic treatment guideline recommendations in Nepal and determine predictive variables with a significant association. This was a retrospective, monocentric observational review to investigate the adherence to endorsed guidelines using the medical records of adults admitted to the hospital with a diagnosis of urinary tract infection (UTI), pneumonia, or skin and soft tissue infection (SSTI) from January 2018 to December 2019. Of the 2,077 medical records that were reviewed (954 UTI, 754 pneumonia, and 369 SSTI), 354 (17%) met the study inclusion criteria, which included 87 UTI, 180 pneumonia, and 87 SSTI patients. Among eligible patients with antibiotic prescriptions, the following were adherent to guideline recommendations: 33 (37.9%) UTI, 78 (43.3%) pneumonia, and 23 (26.4%) SSTI. The overall extent of adherence to hospital antibiotic treatment guidelines for the use of antibiotics among adult inpatients diagnosed with these common infections was 37.9%. Patients who received ceftriaxone (OR = 2.09, 95% CI = 1.18-3.71, p=0.012) and levofloxacin (OR = 4.63, 95% CI = 1.30-16.53, p=0.018) had significantly higher adherence to treatment guidelines. This study revealed a low adherence rate despite the availability of updated guidelines for antibiotic prescriptions. The findings confer an urgent need to confront antibiotic prescription patterns in such tertiary care centers for tailored interventions to improve adherence to antibiotic guidelines.

Anxiety and depression among nurses in COVID and non-COVID intensive care units.

BACKGROUND: Frontline nurses dealing with the coronavirus disease-2019 (COVID-19) pandemic face various mental health challenges ranging from excessive stress and anxiety to severe depression. AIMS: To study the comparative prevalence of anxiety and depression, and their contributing factors, between nurses working in intensive care units (ICU) with COVID-19 patients (COVID ICU) and nurses working in ICU with patients admitted for other reasons (non-COVID ICU). DESIGN: Quantitative comparative cross-sectional study. METHODS: All frontline nurses working in COVID and non-COVID ICUs at a tertiary care university hospital in Nepal were included. The data were collected using Google Forms. The groups were evaluated and compared in terms of various relevant variables with self-designed socio-demographic questionnaire, the validated Nepali version of the Hospital Anxiety and Depression Scale (HADS), and the General Health Questionnaire 12 (GHQ-12). RESULTS: The response rate was 100%. Of the 99 nurses who met the inclusion criteria, three were excluded. Out of the 96 nurses included, psychiatric caseness was present in 82 (85.4%). There was no statistically significant difference in the prevalence of psychiatric caseness, anxiety, and depression between the COVID ICU and non-COVID ICU nurses (caseness of 90.4% vs 79.5%, P = .134; anxiety of 36.5% vs 27.3%, P = .587; and depression of 21.2% vs 9.1%, P = .214, respectively). Among the factors that could potentially lead to psychiatric caseness, anxiety, and depression, statistically significant differences were observed only in relation to sleep disturbances, confidence in caring for patients with COVID-19 and intentions to discontinue current job, all being significantly higher in COVID ICU nurses. CONCLUSION: Anxiety and depression are common in nurses working in both the COVID and non-COVID ICUs, although the difference is not statistically significant. RELEVANCE TO CLINICAL PRACTICE: Early assessment of anxiety and depression in nurses working in all ICUs and their active medical and behavioural interventions are important in protecting this vital work force dealing with the pandemic.

Posterior reversible encephalopathy syndrome in association with exacerbation of chronic obstructive pulmonary disease: a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical and neurological entity. There are varieties of comorbid conditions which are associated with PRES. Chronic obstructive pulmonary disease (COPD) is a rare predisposing factor for the development of PRES. CASE PRESENTATION: A 55 year old female who was being treated for acute exacerbation of COPD developed altered sensorium and multiple episodes of seizure. Characteristic imaging findings and associated clinical symptoms led us to a diagnosis of PRES in our patient. CONCLUSION: Association of PRES and COPD is a rare entity. The diagnosis of PRES should be brought to mind if there is encephalopathy or seizure in COPD exacerbation.

Comparison of outcome predictions by the Glasgow coma scale and the Full Outline of UnResponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit.

Assessment of level of consciousness is very important in predicting patient's outcome from neurological illness. Glasgow coma scale (GCS) is the most commonly used scale, and Full Outline of UnResponsiveness (FOUR) score is also recently validated as an alternative to GCS in the evaluation of the level of consciousness. We carried out a prospective study in 97 patients aged above 16 years. We measured GCS and FOUR score within 24 h of Intensive Care Unit admission. The mean GCS and the FOUR scores were lower among nonsurvivors than among the survivors and were statistically significant (P < 0.001). Discrimination for GCS and FOUR score was fair with the area under the receiver operating characteristic curve of 0.79 and 0.82, respectively. The cutoff point with best Youden index for GCS and FOUR score was 6.5 each. Below the cutoff point, mortality was higher in both models (P < 0.001). The Hosmer-Lemeshow Chi-square coefficient test showed better calibration with FOUR score than GCS. A positive correlation was seen between the models with Spearman's correlation coefficient of 0.91 (P < 0.001).

Intranasal midazolam for rapid sedation of an agitated patient.

Rapidly, establishing a difficult intravenous access in a dangerously agitated patient is a real challenge. Intranasal midazolam has been shown to be effective and safe for rapidly sedating patients before anesthesia, for procedural sedation and for control of seizure. Here, we report a patient in intensive care unit who was on mechanical ventilation and on inotropic support for management of septic shock and who turned out extremely agitated after accidental catheter removal. Intravenous access was successfully established following sedation with intranasal midazolam, using ultrasound guidance.

Intravenous ketamine for treatment of super-refractory convulsive status epilepticus with septic shock: A report of two cases.

Refractory and super-refractory status epilepticus is a life-threatening neurological emergency, associated with high morbidity and mortality. Treatment should be aimed to stop seizure and to avoid cerebral damage and another morbidity. Published data about effectiveness, safety and outcome of various therapies and treatment approaches are sparse and are mainly based on small case series and retrospective data. Here we report successful management of two cases of super-refractory status epilepticus refractory to anesthetic therapy with midazolam and complicated by septic shock, managed successfully with ketamine infusion.

Successful lumbar puncture with Taylor's approach for the diagnostic workup of meningitis in a patient with Ankylosing spondylitis.

Meningitis and encephalitis are the neurological emergencies. As the clinical findings lack specificity, once suspected, cerebrospinal fluid (CSF) analysis should be performed and parenteral antimicrobials should be administered without delay. Lumbar puncture can be technically challenging in patients with ankylosing spondylitis due to ossification of ligaments and obliteration of interspinous spaces. Here, we present a case of ankylosing spondylitis where attempts for lumbar puncture by conventional approach failed. CSF sample was successfully obtained by Taylor's approach.

Apnea testing with continuous positive airway pressure for the diagnosis of brain death in a patient with poor baseline oxygenation status.

Apnea testing is a key component in the clinical diagnosis of brain death. Patients with poor baseline oxygenation may not tolerate the standard 8-10 min apnea testing with oxygen insufflation through tracheal tube. No studies have assessed the safety and feasibility of other methods of oxygenation during apnea testing in these types of patients. Here, we safely performed apnea testing in a patient with baseline PaO2 of 99.1 mm Hg at 100% oxygen. We used continuous positive airway pressure (CPAP) of 10 cm of H2O and 100% oxygen at the flow rate of 12 L/min using the circle system of anesthesia machine. After 10 min of apnea testing, PaO2 decreased to 75.7 mm Hg. There was a significant rise in PaCO2 and fall in pH, but without hemodynamic instability, arrhythmias, or desaturation. Thus, the apnea test was declared positive. CPAP can be a valuable, feasible and safe means of oxygenation during apnea testing in patients with poor baseline oxygenation, thus avoiding the need for ancillary tests.

Sepsis Management in Southeast Asia: A Review and Clinical Experience.

Sepsis is a life-threatening condition that causes a global health burden associated with high mortality and morbidity. Often life-threatening, sepsis can be caused by bacteria, viruses, parasites or fungi. Sepsis management primarily focuses on source control and early broad-spectrum antibiotics, plus organ function support. Comprehensive changes in the way we manage sepsis patients include early identification, infective focus identification and immediate treatment with antimicrobial therapy, appropriate supportive care and hemodynamic optimization. Despite all efforts of clinical and experimental research over thirty years, the capacity to positively influence the outcome of the disease remains limited. This can be due to limited studies available on sepsis in developing countries, especially in Southeast Asia. This review summarizes the progress made in the diagnosis and time associated with sepsis, colistin resistance and chloramphenicol boon, antibiotic abuse, resource constraints and association of sepsis with COVID-19 in Southeast Asia. A personalized approach and innovative therapeutic alternatives such as CytoSorb® are highlighted as potential options for the treatment of patients with sepsis in Southeast Asia.

Recurrent Ischemic Stroke in a Patient with Atrial Myxoma: A Case Report.

Cardiac myxoma is an infrequent but curable cause of ischemic stroke. There are no guidelines addressing the timing of surgery to excise the tumour or for the use of thrombolysis or thrombectomy. We present a case with an ischemic stroke which was diagnosed to have atrial myxoma. She was planned for surgical excision of the tumour but suffered from a second ischemic stroke while awaiting surgery. This article aims to highlight vital aspects of this rare phenomenon and discuss the prospects of the timing of surgery and neurosurgical intervention. The importance of a proper cardiac evaluation in all cases of stroke is highlighted. Keywords: cardiac tumour; myxoma; cardiac surgery; ischemic stroke.

Characteristics and Outcome of Patients with COVID-19 Undergoing Invasive Mechanical Ventilation for Respiratory Failure in a Tertiary Level Hospital in Nepal.

BACKGROUND: Corona virus disease 2019 has become a global health issue. The goal of this study was to investigate the characteristics and outcomes of patients with corona virus disease 2019 undergoing invasive mechanical ventilation and identify factors associated with mortality. METHODS: Ninety four consecutive critically ill patients with confirmed corona virus disease 2019 undergoing invasive mechanical ventilation were included in this retrospective, single-center, observational study. The outcome variable was mortality of patients undergoing invasive mechanical ventilation and factors associated with it during intensive care unit stay. RESULTS: Seventy nine (84%) out of 94 patients with confirmed corona virus disease 2019 who underwent invasive mechanical ventilation didn't survive. Ninety four percent of patients who had Type 2 Diabetes Mellitus did not survive in comparison to 72 percent of patients who didn't have Type 2 Diabetes Mellitus. Similarly, 48 (94.1%) out of 51 patients with a positive C-reactive protein value didn't survive in comparison to 31 (72%) out of 43 patients with a negative C-reactive protein. CONCLUSIONS: The presence of Type 2 Diabetes Mellitus and a positive C-reactive protein value were strongly associated with mortality. Patients with a Sequential organ failure assessment score of more than eight at intensive care unit admission and peak D-dimer level of more than or equal to two during intensive care unit stay didn't show significant association with mortality. These findings need further exploration through larger prospective studies.

Combination of convalescent plasma therapy and repurposed drugs to treat severe COVID-19 patient with multimorbidity.

Combination of convalescent plasma therapy and repurposed drugs such as dexamethasone and remdesivir could be beneficial for severe COVID-19 patients with obesity and chronic diseases such as diabetes and hypertension.

Clinical Outcome of Patients Hospitalized in a Tertiary Care Hospital of Nepal with Confirmed Influenza A/pdm 09(H1N1) in 2018/2019.

BACKGROUND: It is important to monitor the cases affected by Influenza A/pdm09 as it is difficult to predict the behavior of Influenza A/pdm09 virus as a seasonal influenza. This study aimed to measure the clinical outcomes of patients with Influenza A/pdm 09 in a tertiary care hospital of Nepal in post pandemic period. METHODS: A retrospective study was conducted in a tertiary care hospital of central Nepal to record the confirmed cases of Influenza A/pdm 09 from April 2018 to March 2019.The medical records of those patients whose throat sample had been sent to laboratory for testing Influenza A/pdm 09 were referred. The outcomes were then abstracted from the hospital system/medical record department. RESULTS: Among 141 influenza suspected cases, 35.5%(N=50) were Influenza A/Pdm 09 positive. Both male and female were equal in distribution (N=25). Most positive cases were from the age group of 15-64 yrs. Out of total,72 %( N=36) with Influenza A/pdm 09 were discharged after treatment whereas case fatality rate was 22 %( N=11). Twenty-one positive cases were admitted in intensive care unit in which 52.4% expired. The average length of stay in I.C.U and mechanical ventilation were 6.4 days and 5.8 days respectively. CONCLUSIONS: This study in post pandemic period in Nepal shows the outcomes of patients with confirmed influenza A/pdm 09 in a year time period with comparably high case fatality rate.

Acute mountain sickness induced diabetic ketoacidosis managed with hemodialysis: A case report.

INTRODUCTION: The risk of developing ketoacidosis in patients with type 1 diabetes at high altitude is high. Anorexia associated with acute mountain sickness, dehydration and additional exercise associated with climbing exacerbates the generation of ketones and the development of ketoacidosis. CASE PRESENTATION: A 33-year-old gentleman with known history of uncontrolled type 1 diabetes mellitus trekked to Everest Base Camp at an altitude of 3440 m and became unwell. He developed altered sensorium and shortness of breath. He ingested eight tablets of acetazolamide (250 mg each) to address these symptoms. Upon presentation to emergency, he was diagnosed with severe diabetes ketoacidosis (DKA) with shock. Resuscitation was started with fluid, insulin, vasopressors and mechanical ventilation. Despite adequate fluid resuscitation, insulin, bicarbonates and other supportive measures, his acidosis and shock persisted and then managed with hemodialysis. After the first session of hemodialysis, improvement in acidosis and shock was noted. He was successfully extubated and later discharged. DISCUSSION: In this case report, DKA due to acute mountain sickness was complicated by acetazolamide use and noncompliance to his regular insulin intake. There is no proper guideline regarding the role of renal replacement therapy in management of DKA. However, evidence of hemodialysis in DKA is limited to few case reports. Improvement seen in our patient after dialysis is related to dialyzable nature of acetazolamide. CONCLUSION: We present a case of a severe DKA potentially precipitated by acute mountain sickness, use of acetazolamide, noncompliance to his regular insulin intake and managed with hemodialysis in addition to conventional treatment for DKA.

Management of nitrobenzene poisoning with oral methylene blue and vitamin C in a resource limited setting: A case report.

Nitrobenzene can cause life threatening methaemoglobinemia. Its management includes the use of intravenous methylene blue to reduce the iron moiety from its ferric to ferrous state. Due to unavailability of intravenous preparation, enteral methylene blue was used in our case. This case report is to highlight that even oral preparations can be successfully used in a resource limited setting where often intravenous preparations are unavailable.

Staphylococcal toxic shock syndrome in a lactating mother with breast abscess: A case report.

INTRODUCTION: The highest risk for Staphylococcal Toxic Shock Syndrome are female patients with pre-existing Staphylococcal vaginal colonization who frequently use contraceptive sponges, diaphragms or tampons. In addition patients with burns, soft tissue injures, retained nasal packing, post-abortion, post-surgical, post intrauterine device placement and abscess formation are also at high risk. CASE PRESENTATION: A 19 years old female complaint of high fever with altered level of consciousness. She also had history of nausea, vomiting, diarrhea and pain on her left breast for 5 days. She developed desquamation on her palms and soles on the day three of her admission to ICU. Ultrasonography of her left breast showed 2*2*1 cm abscess collection and the culture report from breast abscess showed Staphylococcus aureus, sensitive to clindamycin, vancomycin and resistant to methicillin. She showed clinical improvement after commencing vancomycin and clindamycin as per culture sensitivity report of breast abscess. DISCUSSION: Toxic shock syndrome secondary to breast abscess in adult is infrequently reported. The diagnosis of Toxic shock syndrome is made by the Centers for Disease Control and Prevention (CDC) definition. Antibiotics for treatment of this condition should include a penicillinase-resistant penicillin, cephalosporin, or vancomycin (in methicillin-resistant S. aureus prevalent areas) in combination with either clindamycin or linezolid. CONCLUSION: Treatment for breast abscess warrants incision and drainage as important as antibiotics with anti-toxin. Focused history, physical examination, and laboratory investigations are crucial for the diagnosis and management of this condition.

Symptomatic Hyponatremia following Bowel Preparation for Colonoscopy: A Case Report.

Colonoscopy is considered a gold standard tool for the diagnostic evaluation of colorectal diseases. Bowel preparation, a pre-requisite for colonoscopy, usually involves ingestion of purgatives for the cleansing of the bowel so that visualization is not obscured during the procedure. Commonly used preparations are sodium phosphate-based solutions, sodium picosulphate and polyethylene glycol. The use of such preparations is associated with electrolyte disturbances, commonly hyponatremia. Hyponatremia is usually seen with sodium phosphate based solutions and is rare with polyethylene glycol. Symptomatic hyponatremia, however, is rare following bowel preparation and is attributable to other factors as well, such as the age of patient, non-osmotic release of antidiuretic hormone and the procedure itself. In this report, we discuss a case of severe symptomatic hyponatremia observed in a 71-year-old gentleman who underwent polyethylene glycol based bowel preparation for colonoscopy.

Lamotrigine induced toxic epidermal necrolysis: A case report.

INTRODUCTION: A wide spectrum of cutaneous adverse reactions ranging from simple maculopapular rashes to more severe and life-threatening reactions like Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis(TEN) have been described after exposure to many antiepileptic drugs. Although the adverse effect following lamotrigine has been reported after a low initial dosage, the risk of developing TEN is relatively rare. CASE REPORT: We present a 23-year-old female, 6 months post-partum, a case of complex partial seizure, who developed TEN after 14 days of monotherapy with lamotrigine. She was put on steroids and other supportive management. After a tempestuous course of 9 days in ICU, she made an eventful recovery. DISCUSSION: Lamotrigine, a chemically different newer antiepileptic, if rapidly titrated and used in conjunction with valproate can cause exfoliative dermatitis-like TEN, but at lower doses and as a monotherapy, female, post-partum, probably due to hormonal factors and strong association between HLA-B*1502 and AED (Antiepileptic drug)-induced SJS/TEN in patients of Asian ethnicity could be other contributing cause. Also, lesser use of lamotrigine in developing nations might have led to a lesser incidence of serious cutaneous adverse reactions. The SCORTEN (Severity-of-illness score for toxic epidermal necrolysis) is the most widely used system to standardize the evaluation of risk and prognosis in patients with TEN. CONCLUSION: Though rare but TEN can occur following lamotrigine monotherapy. Prompt diagnosis, withdrawal of offending agent, and timely proper supportive care might help in lowering the mortality.

Delayed Neurological Recovery After Ultrasound-Guided Brachial Plexus Block: A Case Report.

INTRODUCTION: Brachial plexus blocks are frequently practiced and safe mode of anaesthsia. Although minor complications may occur, major complications are a rarity. However, we report a rare case of prolonged supraclavicular brachial plexus block which required almost 4 months to recover without a perceivable cause. CASE PRESENTATION: A 22-year-old gentleman posted for open reduction and internal fixation of both forearm bones was administered an ultrasound-guided supraclavicular brachial plexus block. The intra-operative period was uneventful. However, the block persisted for a very prolonged period of time. All perceivable causes were ruled out. A total of 19 weeks was required for the entire block to regress with no residual neurological deficits thereafter. CONCLUSION: Although peripheral neuropathies are known complications of peripheral nerve blocks, such a prolonged brachial plexus block is a rare event. The only plausible cause for the patient's condition could have been the prolonged drug effect; however, it has been rarely documented.