Epidemiology and management trends of patients with severe sepsis and septic shock in Trinidadian Intensive Care Units: A prospective multicenter trial

Objectives: To investigate the epidemiology, management and predictors of mortality in severe sepsis. Design and Methodology: Prospective observational study in 4 Trinidadian Intensive Care Units (ICU) over a one year period August 2017-August 2018. Physiologic and treatment data was collected on admission to ICU and patients were followed up until ICU discharge and then at 28 days to determine mortality. Results: 163 patients fit the criteria for severe sepsis and were enrolled. Twenty-eight day and ICU mortality rate were 42% (68) and 34 % (56) respectively. Case distribution by the various hospitals were San Fernando General Hospital 62% (101), Port of Spain General Hospital 16% (26), Eric Williams Medical Sciences Complex 12.3% (20) and Sangre Grande Hospital 9.8% (16). The most common source of sepsis was pulmonary (54%) followed by abdominal (17%) and urological sepsis (14%). Acute Kidney Injury (AKI) was present in 71% (115) patients and 43% (46) of patients with stage 2 and above AKI received Renal Replacement Therapy (RRT) in the ICU. In the regression model, the only factors that were found to predict both 28 day and ICU mortality were stage 2 AKI [OR 6.2 (95% CI 1.7- 23.1, p = .007)], stage 3 AKI [OR 7.2 (95% CI, 2.1-24.0, p=.001)] , mean arterial pressure of < 60mmHg in the first 24 hours [OR 10.8 (95% CI 1.7-68.1, p= .001)], presence of either moderate-severe Acute Respiratory Distress Syndrome [OR 4.1 (95% CI 1.8 ­ 9.2, p = .002)] and Acute Physiology, Age, Chronic Health Evaluation (APACHE) II score [OR 1.08 (95% CI, 1.0-1.2, p=.039)]. Conclusion: Severe sepsis is associated with a high hospital mortality rate and this sepsis burden varies according to region. Limited access to RRT remains a problem in certain centers.

Risk-adjusted outcome evaluation in a multidisciplinary intensive care unit.

OBJECTIVE: To evaluate the outcome of a multidisciplinary Intensive Care Unit (ICU) by applying the Acute Physiology and Chronic Health Evaluation (APACHE II) and Paediatric Index of Mortality (PIM)--version-2 scoring systems. SUBJECTS AND METHODS: Two-hundred and seventeen patients admitted consecutively to the ICU during a period of one year were included for prospective data collection. Data recorded were demographics, diagnoses at admission, APACHE II score for adults and PIM -2 score for children, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratios were calculated. Calibration and discriminant function of the systems were done by Hosmer-Lemeshow analysis and Receiver Operating Characteristic (ROC) curves. RESULTS: In adults, the mean APACHE II score was 14.3 +/- 8.3; in survivors, it was 8.7 +/- 5.9 (SD) when compared to 21.2 +/- 5.9 (SD) in non-survivors (p < 0.0001). The predicted mortality in adults by APACHE II was 16.5%, the observed mortality being 19.8%. The predicted mortality by the PIM-2 in children was 34.8% with the observed mortality rate being 30%. The overall mean duration of stay was 5.2 +/- 7.5 days. The goodness-of-fit for APACHE II and PIM-2 systems were fair (HL chi-square, p = 0.71, 0.69, respectively). The area under the ROC curve was 0.88 for APACHE II and 0.62 for PIM-2. CONCLUSION: Evaluation of risk-adjusted outcome in multidisciplinary ICUs is challenging because of the need to apply more than one prognostic scoring system.

An evaluation of the intensive care unit resources and utilization in Trinidad.

OBJECTIVES: To evaluate resources and utilization of Intensive Care Units in Trinidad and Tobago. DESIGN AND METHODS: This was a prospective observational study to evaluate Intensive Care Units (ICU) of three public and two private hospitals in Trinidad with respect to their infrastructure, process of care and patient outcome. Structure of ICUs was assessed by interviews and personal observations. A Cost Block Model was used to determine the expenditure for ICUs. The process of ICU was assessed by Therapeutic Intervention Scoring System (TISS-28). For outcome evaluation, two prognostic scoring systems namely Simplified Acute Physiology Score (SAPS II) and Paediatric Index of Mortality-2 (PIM-2) were used RESULTS: The total number of ICU beds was 27. The overall bed occupancy was 66.2%. One hundred and eighteen patients consecutively admitted to ICU during a two-month period were enrolled for process and outcome evaluation. The overall median age of patients was 44 years [Interquartile range (IQR) 25, 59]. The mean cost per patient in the public hospitals was TT $64,746 compared to $77,000 in a private hospital. The average total daily TISS per patient was 27.01 +/- 5.4 (SD). The median length of stay was five days (IQR 2, 9). The overall predicted mortality was 32.9%, the observed mortality was 29.7% and thus the standardized mortality ratio (SMR) was 0.9. CONCLUSIONS: The overall bed availability in ICUs with respect to Trinidad and Tobago's population and case-mix is low compared to developed countries, although the process of ICU care is comparable. Outcome of patients was good in terms of risk-adjusted mortality. The study highlights the need to further increase bed-strength and optimize the resource utilization of ICUs in Trinidad and Tobago.

Risk-adjusted outcome evaluation in a multidisciplinary intensive care unit / Evaluación del resultado clínico ajustado por riesgo en una unidad multidisciplinaria de cuidados intensivos

OBJECTIVE: To evaluate the outcome of a multidisciplinary Intensive Care Unit (ICU) by applying the Acute Physiology and Chronic Health Evaluation (APACHE II) and Paediatric Index of Mortality (PIM)--version-2 scoring systems. SUBJECTS AND METHODS: Two-hundred and seventeen patients admitted consecutively to the ICU during a period of one year were included for prospective data collection. Data recorded were demographics, diagnoses at admission, APACHE II score for adults and PIM -2 score for children, the duration of ICU stay and hospital outcome. Predicted mortality and standardized mortality ratios were calculated. Calibration and discriminant function of the systems were done by Hosmer-Lemeshow analysis and Receiver Operating Characteristic (ROC) curves. RESULTS: In adults, the mean APACHE II score was 14.3 +/- 8.3; in survivors, it was 8.7 +/- 5.9 (SD) when compared to 21.2 +/- 5.9 (SD) in non-survivors (p < 0.0001). The predicted mortality in adults by APACHE II was 16.5%, the observed mortality being 19.8%. The predicted mortality by the PIM-2 in children was 34.8% with the observed mortality rate being 30%. The overall mean duration of stay was 5.2 +/- 7.5 days. The goodness-of-fit for APACHE II and PIM-2 systems were fair (HL chi-square, p = 0.71, 0.69, respectively). The area under the ROC curve was 0.88 for APACHE II and 0.62 for PIM-2. CONCLUSION: Evaluation of risk-adjusted outcome in multidisciplinary ICUs is challenging because of the need to apply more than one prognostic scoring system.

Objetivo: Evaluar el resultado clínico de una Unidad de Cuidados Intensivos (UCI) multidisciplinaria, aplicando la versión 2 de los sistemas de puntuación de la Evaluación de la fisiología aguda y la enfermedad crónica, versión II (conocida por su sigla en inglés como APACHE II) y del Índice Pediátrico de Mortalidad (IPM). Sujetos y Métodos: Doscientos diecisiete pacientes ingresados consecutivamente en la UCI durante un período de un año fueron incluidos en la recopilación de datos prospectivos. Los datos registrados fueron la demografía, los diagnósticos de ingreso, la puntuación APACHE II para adultos y la puntuación IPM-2 para niños, la duración de la estadía en la UCI, y el resultado de la hospitalización. Se calcularon las proporciones (ratios) de mortalidad predicha y mortalidad estandarizada. La calibración y la función discriminante de los sistemas se realizaron mediante el análisis Hosmer-Lemeshow y las curvas de características operativas del receptor (ROC). Resultados: En los adultos, la puntuación APACHE II media fue 14.3 ± 8.3; en los sobrevivientes fue 8.7 ± 5.9 (SD) en comparación con 21.2 ± 5.9 (SD) en los no sobrevivientes, (p < 0.0001). La mor-talidad predicha en los adultos por APACHE II fue 16.5%, siendo la mortalidad observada 19.8%. La mortalidad predicha para los niños según IPM-2 fue 34.8% con una tasa de mortalidad observada de 30%. La duración general promedio de estadía fue 5.2 ± 7.5 días. La bondad de ajuste para los sistemas APACHE II y IPM-2 fue aceptable (HL chi-square, p = 0.71, 0.69, respectivamente). El área bajo la curva de ROC fue 0.88 para APACHE II y 0.62 para IPM-2

An evaluation of the intensive care unit resources and utilization in Trinidad / Una evaluación de los recursos y la utilización de las unidades de cuidados intensivos en trinidad

OBJECTIVES: To evaluate resources and utilization of Intensive Care Units in Trinidad and Tobago. DESIGN AND METHODS: This was a prospective observational study to evaluate Intensive Care Units (ICU) of three public and two private hospitals in Trinidad with respect to their infrastructure, process of care and patient outcome. Structure of ICUs was assessed by interviews and personal observations. A Cost Block Model was used to determine the expenditure for ICUs. The process of ICU was assessed by Therapeutic Intervention Scoring System (TISS-28). For outcome evaluation, two prognostic scoring systems namely Simplified Acute Physiology Score (SAPS II) and Paediatric Index of Mortality-2 (PIM-2) were used RESULTS: The total number of ICU beds was 27. The overall bed occupancy was 66.2%. One hundred and eighteen patients consecutively admitted to ICU during a two-month period were enrolled for process and outcome evaluation. The overall median age of patients was 44 years [Interquartile range (IQR) 25, 59]. The mean cost per patient in the public hospitals was TT $64,746 compared to $77,000 in a private hospital. The average total daily TISS per patient was 27.01 +/- 5.4 (SD). The median length of stay was five days (IQR 2, 9). The overall predicted mortality was 32.9%, the observed mortality was 29.7% and thus the standardized mortality ratio (SMR) was 0.9. CONCLUSIONS: The overall bed availability in ICUs with respect to Trinidad and Tobago's population and case-mix is low compared to developed countries, although the process of ICU care is comparable. Outcome of patients was good in terms of risk-adjusted mortality. The study highlights the need to further increase bed-strength and optimize the resource utilization of ICUs in Trinidad and Tobago.

OBJETIVOS: Evaluar los recursos y su utilización en las Unidades de Cuidados Intensivos en Trinidad y Tobago. DISEÑO Y MÉTODOS: Se trata de un estudio prospectivo observacional con el propósito de evaluar las Unidades de Cuidados Intensivos de tres hospitales públicos y dos privados en Trinidad, con respecto a su infraestructura, proceso de cuidado y respuesta clínica (resultado) del paciente. La estructura de las UCIs fue evaluada mediante entrevistas y observaciones personales. Un modelo de bloques del costo fue usado a fin de determinar los gastos en relación con las UCIs. El proceso de la UCI fue evaluado mediante el Sistema de Puntuación de Intervención Terapéutica (TISS-28). Para la evalua-ción del resultado clínico, se utilizaron dos sistemas de puntuación pronóstica, a saber, la puntuación simplificada de fisiología aguda (SAPS II) y el Índice Pediátrico de Mortalidad (PIM2). RESULTADOS: El número total de camas de UCI fue 27. La ocupación general de las camas fue de 66.2%. Los ciento dieciocho pacientes ingresados consecutivamente en la UCI durante un período de dos meses, fueron incorporados a la evaluación del proceso y los resultados. La edad mediana general de todos los pacientes fue de 44 años y el rango intercuartil (IQR) 25,59. El costo medio por paciente en los hospitales públicos fue TT $64 746 en comparación con $ 77 000 en un hospital privado. Según el TISS, el total promedio diario por paciente fue 27.01 ± 5.4 (SD). El tiempo mediano de estadía fue de 5 días (IQR 2, 9). La mortalidad general anticipada fue de 32.9%, la mortalidad observada fue de 29.7%, y por consiguiente la razón de mortalidad estandarizada (SMR) fue 0.9. CONCLUSIONES: La disponibilidad total de camas en las UCIs con respecto a la población y la casuística de Trinidad y Tobago, es baja en comparación con los países en desarrollo, aunque el proceso de cuidado de las UCIs es comparable. El resultado clínico de los pacientes fue bueno en términos de la...

Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison.

This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.

Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison.

This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.

Off-pump coronary artery bypass surgery: anaesthetic implications and the Trinidad experience / Cirugía de bypass coronario sin circulación extracorpórea: implicaciones anestésicas y la experiencia de Trinidad

OBJECTIVES: To review the evolution of off-pump coronary artery bypass surgery with particular reference to the anaesthetic and perioperative implications. FINDINGS: After review of the literature regarding coronary artery bypass grafting, the adverse effects of cardiopulmonary bypass on the various systems are discussed The development and the present status of off-pump coronary artery bypass surgery and its anaesthetic implications are reviewed These are discussed under the categories of preoperative, intra-operative and postoperative concerns. In Trinidad and Tobago, various cardiac surgical teams from different parts of the world conduct cardiac surgery. The cardiac anaesthesia team therefore has the unique opportunity of working with several teams who employ different techniques. CONCLUSIONS: Off-pump coronary artery bypass grafting surgery has distinct anaesthetic implications. In Trinidad and Tobago, the majority (85%) of the coronary revascularization surgeries are being done by this technique. Because of the lower cost and improved outcomes, this technique could be recommended to other developing countries of the region.

Objetivos: Examinar la evolución de la cirugía de bypass coronario (revascularización coronaria) sin circulación extracorpórea, con referencia particular a las implicaciones anestésicas y perioperatorias. Hallazgos: Tras examinar la literatura en relación con el bypass coronario con injerto, se discuten los efectos adversos del bypass cardiopulmonar en los distintos sistemas. Se analiza el desarrollo y el estatus presente de la cirugía de bypass coronario sin circulación extracorpórea (“sin bomba”) y sus implicaciones anestésicas. El análisis se realiza bajo las categorías de problemas pre-operatorios, intra-operatorios y post-operatorios. En Trinidad y Tobago, varios equipos de cirugía cardiaca de diferentes partes del mundo llevan a cabo cirugía cardiaca. Por lo tanto, el equipo que tiene a su cargo la anestesia durante las intervenciones quirúrgicas del corazón tiene la oportunidad excepcional de trabajar con varios equipos que emplean diferentes técnicas. Conclusiones: La cirugía de injerto de bypass coronario sin circulación extracorpórea tiene claras implicaciones anestésicas. En Trinidad y Tobago, la mayoría (85%) de las cirugías de revascularización coronaria, se realizan mediante esta técnica. Debido a su bajo costo y al mejoramiento en sus resultados, esta técnica podría recomendarse a los países en desarrollo de la región.

Off-pump coronary artery bypass surgery: anaesthetic implications and the Trinidad experience.

OBJECTIVES: To review the evolution of off-pump coronary artery bypass surgery with particular reference to the anaesthetic and perioperative implications. FINDINGS: After review of the literature regarding coronary artery bypass grafting, the adverse effects of cardiopulmonary bypass on the various systems are discussed The development and the present status of off-pump coronary artery bypass surgery and its anaesthetic implications are reviewed These are discussed under the categories of preoperative, intra-operative and postoperative concerns. In Trinidad and Tobago, various cardiac surgical teams from different parts of the world conduct cardiac surgery. The cardiac anaesthesia team therefore has the unique opportunity of working with several teams who employ different techniques. CONCLUSIONS: Off-pump coronary artery bypass grafting surgery has distinct anaesthetic implications. In Trinidad and Tobago, the majority (85%) of the coronary revascularization surgeries are being done by this technique. Because of the lower cost and improved outcomes, this technique could be recommended to other developing countries of the region.

Provision of anaesthesia for porcine cardiac transplantation at the veterinary school in Trinidad and Tobago.

A successful heterotopic cardiac transplantation was performed between sibling female Yorkshire Juvenile swine. Adequate pre-medication with azaperone and a smooth induction were ensured for both pigs, which were anaesthetized simultaneously with sodium thiopentone followed by endotracheal intubation and intermittent positive pressure ventilation. Inhalation anaesthetic agents were used for maintenance, neuromuscular blockade was achieved with cisatracurium and both fentanyl and tramadol were used to provide analgesia. Invasive monitoring was used in both the donor and recipient. Central venous pressure (CVP) was maintained at > 10 cm H2O and mean arterial pressure (MAP) > 60 mmHg. Heparin was injected during the surgical dissection of the heart in the donor to prevent coronary thrombosis and prior to aortic side clamping for end-to-side anastomosis of the donor heart in the recipient abdomen. After transplantation, the cardiovascular parameters of the recipient showed a MAP of 85-105 mmHg and a CVP of 8-10 cm H2O while echocardiography of the transplanted heart confirmed an ejection fraction (EF) of 80%. A functional anaesthetic team was assembled and trained to provide anaesthesia for porcine cardiac transplantation. The transplanted heart suffered pump failure after 69 days and was excised for performance of tissue analysis.

Provision of anaesthesia for porcine cardiac transplantation at the veterinary school in Trinidad and Tobago

A successful heterotopic cardiac transplantation was performed between sibling female Yorkshire Juvenile swine. Adequate pre-medication with azaperone and a smooth induction were ensured for both pigs, which were anaesthetized simultaneously with sodium thiopentone followed by endotracheal intubation and intermittent positive pressure ventilation. Inhalation anaesthetic agents were used for maintenance, neuromuscular blockade was achieved with cisatracurium and both fentanyl and tramadol were used to provide analgesia. Invasive monitoring was used in both the donor and recipient. Central venous pressure (CVP) was maintained at > 10 cm H2O and mean arterial pressure (MAP) > 60 mmHg. Heparin was injected during the surgical dissection of the heart in the donor to prevent coronary thrombosis and prior to aortic side clamping for end-to-side anastomosis of the donor heart in the recipient abdomen. After transplantation, the cardiovascular parameters of the recipient showed a MAP of 85-105 mmHg and a CVP of 8-10 cm H2O while echocardiography of the transplanted heart confirmed an ejection fraction (EF) of 80. A functional anaesthetic team was assembled and trained to provide anaesthesia for porcine cardiac transplantation. The transplanted heart suffered pump failure after 69 days and was excised for performance of tissue analysis

Use of herbal medicines by surgical outpatients in Trinidad

Herbal medications have been used worldwide before the time of the Egyptians. The Greeks, medical doctors, apothecaries and traditional healers all used herbal medicines throughout the ages. There is today an increase in the use of alternative therapies worldwide. In 1993 Australian alternative medicine use was 48.5 percent in the population. In 1997 use in the USA population was estimated at 42.1 percent, an increase from 33.8 percent in 1990. Traditionally in the Caribbean home remedies based on herbs have prominence among alternative therapies. In the media, well-known celebrities advocate the use of alternative therapies while the conventional medical fraternity argues it. The prevalence of alternative medication use by surgical patients is unfortunately only sparsely researched in the Caribbean. Our studies looked at adult surgical clinic patients in Trinidad. Over 70 percent of the patients interviewed used some form of herbal therapy (herbal medicines, bush medicine, bush tea). Some common herbs used by patients in our study were garlic, ginseng and gingko, which are known to affect clotting and may put the surgical patient at risk for bleeding. Patients also were using prescription medication and few informed their physician of their concurrent use. Various herbal medicines are known to have effects on the immune system, clotting, hepatic function, neurological status and the cardiovascular system. These changes may impact on the surgical patient, therefore their surgeons and anaesthetists need to ask specifically about herbal drug use to prevent unknown drug interaction and risk to patients

A Study on the Knowledge, Attitude and Practices of Diabetic Patients with regard to the Physiological Health Parameters and Self-management Practices, and the Impact these Factors have on Quality of Life and Disease Complications

Diabetes Mellitus (DM) prevalence in Trinidad and Tobago (T&T) has increased over the years. Studies have been done on the Knowledge, Attitude and Practices (KAP) of diabetic patients in the public health sector. None have been done among members of private associations within T&T, which are focused on improving their members' lifestyle through education, with the aim of prevention/self management of chronic illnesses including diabetes. These persons may be more knowledgeable and motivated to take necessary steps in diabetes self-management.

Use of herbal medicines by surgical outpatients in Trinidad

Herbal medications have been used worldwide before the time of the Egyptians. The Greeks, medical doctors, apothecaries and traditional healers all used herbal medicines throughout the ages. There is today an increase in the use of alternative therapies worldwide. In 1993 Australian alternative medicine use was 48.5 percent in the population. In 1997 use in the USA population was estimated at 42.1 percent, an increase from 33.8 percent in 1990. Traditionally in the Caribbean home remedies based on herbs have prominence among alternative therapies. In the media, well-known celebrities advocate the use of alternative therapies while the conventional medical fraternity argues it. The prevalence of alternative medication use by surgical patients is unfortunately only sparsely researched in the Caribbean. Our studies looked at adult surgical clinic patients in Trinidad. Over 70 percent of the patients interviewed used some form of herbal therapy (herbal medicines, bush medicine, bush tea). Some common herbs used by patients in our study were garlic, ginseng and gingko, which are known to affect clotting and may put the surgical patient at risk for bleeding. Patients also were using prescription medication and few informed their physician of their concurrent use. Various herbal medicines are known to have effects on the immune system, clotting, hepatic function, neurological status and the cardiovascular system. These changes may impact on the surgical patient, therefore their surgeons and anaesthetists need to ask specifically about herbal drug use to prevent unknown drug interaction and risk to patients (AU)