Anuja Abayadeera

Applicability of the APACHE II model to a lower middle income country

Purpose: To determine the utility of APACHE II in a low‐and middle‐income (LMIC) setting and the implications of missing data. Materials and methods: Patients meeting APACHE II inclusion criteria admitted to 18 ICUs in Sri Lanka over three consecutive months had data necessary for the calculation of APACHE II, probabilities prospectively extracted from case notes. APACHE II physiology score (APS), probabilities, Standardised (ICU) Mortality Ratio (SMR), discrimination (AUROC), and calibration (C‐statistic) were calculated, both by imputing missing measurements with normal values and by Multiple Imputation using Chained Equations (MICE). Results: From a total of 995 patients admitted during the study period, 736 had APACHE II probabilities calculated. Data availability for APS calculation ranged from 70.6% to 88.4% for bedside observations and 18.7% to 63.4% for invasive measurements. SMR (95% CI) was 1.27 (1.17, 1.40) and 0.46 (0.44, 0.49), AUROC (95% CI) was 0.70 (0.65, 0.76) and 0.74 (0.68, 0.80), and C‐statistic was 68.8 and 156.6 for normal value imputation and MICE, respectively. Conclusions: An incomplete dataset confounds interpretation of prognostic model performance in LMICs, wherein imputation using normal values is not a suitable strategy. Improving data availability, researching imputation methods and developing setting‐adapted and simpler prognostic models are warranted. HighlightsAn incomplete dataset confounds interpretation of APACHE II performance in LMICs.Imputation of missing data with normal values is not appropriate for LMICs.Developing a setting‐adapted and simpler prognostic model for LMICs is warranted.

Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A consensus statement

BACKGROUND & AIMS Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia-Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia-Pacific and the Middle East. METHODS The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia-Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions. RESULTS Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU. CONCLUSIONS The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes.

Phaeochromocytoma during pregnancy: anaesthetic management for a caesarean section combined with bilateral adrenalectomy

Phaeochromocytoma in pregnancy is associated with high maternal and neonatal mortality rates. Recently, improved management and antenatal diagnosis have reduced the maternal mortality rate below 1% and neonatal mortality rate below 15% respectively.

Oesophago-gastrectomy in a patient with haemophilia A.

With recent improvements in pre- and postoperative care, major complex surgical procedures are now performed in patients with coagulatory disorders [1]. However, these are seldom reported in the surgical literature. Haemophilia A is an inherited, X-linked, recessive disorder resulting in deficiency of functional plasma coagulation factor(F) VIII and may result in excessive bleeding during and following surgery. The severity of haemophilia, the factor level and the type of surgery will determine the extent of bleeding. Here, we report a case of a 34-year-old male with haemophilia A who presented with intermittent localized epigastric pain and episodes of belching of 4 months duration. He had no dysphagia, melaena, loss of appetite or loss of weight. The clinical examination was unremarkable. Upper gastrointestinal endoscopy showed 1 cm polypoid growth at the gastro-oesophageal junction. Multiple biopsies taken under cryoprecipitate cover were reported as adenocarcinoma. A CT scan of the abdomen showed a localized growth in the gastrooesophageal junction. There was no radiological evidence of metastases. Since the tumour was small and well localized, the oncological opinion was to go ahead with surgery. Preoperative FVIII assay showed a 30% level, indicating mild deficiency. Preoperative APTT was 42 s (normal 25‐40 s) and the Internationally Normalised Ratio (INR) was 1.04. FVIII levels were raised from 30% to 100% by transfusing anti-haemophilic factor (AHF) 30 min prior to surgery. Open Ivor Lewis oesophago-gastrectomy, feeding jejunostomy and a hand sewn anastomosis was performed. The SonoSurg (Olympus Medical Systems Corp., Tokyo, Japan) (ultrasonic dissector/ coagulator) was used as the main tool of dissection to minimize bleeding and also to reduce operating time. The total blood loss during surgery was 400 mL. To maintain adequate coagulation during the first 24 h, AHF was transfused, and thereafter, cryoprecipitate was transfused until the fifth postoperative day. Jejunostomy feeding was commenced 6-h postoperatively. The patient was managed in the intensive care unit for 48 h. Removal of drains, tubes and staples were carried out under AHF and cryoprecipitate cover. Oral feeds were commenced during the second week after a gastrograffin study excluded an anastomotic leak. Histology of the specimen also confirmed the diagnosis of a well differentiated adeno-carcinoma, pT1pNopMx. The patient presented 2 weeks following discharge from the hospital with melaena. Upper GI endoscopy showed oozing from the granulation tissue at the site of anastomosis. Symptoms responded to i.v. omeprazole and administration of AHF. Subsequent endoscopy after 3 weeks showed a well healed anastomosis. In conclusion, early oesophageal cancer (especially adenocarcinoma) can be cured, if the tumour is excised completely [2]. The same surgical principles should be applied even to patients with major coagulation disorders, provided that pre- and postoperative optimization of coagulation are achieved. During surgery, we used the SonoSurg to minimize bleeding and operating time [3,4]. Bleeding may be further reduced, if minimally invasive surgical techniques are practised [5]. We did not adopt a laparoscopic approach because of lack of expertise in our centre. Therefore, in the present era of modern technology and advanced surgical care, even patients suffering from inherited bleeding disorders, such as haemophilia can be offered major complex surgical procedures with excellent outcome, provided, it is carried out by a team of experienced personnel in centres with adequate facilities.

Critical care junior doctors' profile in a lower middle-income country: A national cross-sectional survey

Background and Aims: Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country. Materials and Methods: This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire. Results: Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10. Conclusion: Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.

Acquired-Hypernatraemia in the Intensive Care Units

Objectives: Determine the incidence and predisposing factors of acquired-hypernatraemia in the intensive care units (ICU) and its impact on the outcome.

Anaesthesia for seperation of conjoined twins

Thoraco omphalopagus type accounts for about 74% of all conjoined twins. This is the first reported case of successful separation of conjoined twins in Sri Lanka. Need of detailed preoperative assessment, multidisciplinary team approach, pre- operative meetings to collate information, formulating an agenda and developing a plan of action, organised approach to anaesthetising two individuals simultaneously and meticulous postoperative care is emphasised. Responsibility of anaesthesia team in anaesthetizing two individual patients simultaneously is highlighted. DOI: http://dx.doi.org/10.4038/slja.v23i1.7491

Allogeneic bone marrow transplant in a child with thalassaemia

Transfusion dependent thalassaemia is a significant problem in Sri Lanka. In a study published in 2000, it was estimated that there were approximately 2000 transfusion dependent beta thalassaemia and HbE patients in Sri Lanka and the expenditure on them accounted for approximately 5% of the recurrent health budget of the country [1]. This number has by and large remained static over the past decade. An Italian group reported in 2006, that the mean cost of treatment for thalassaemia major was € 1242/patient/month with 55.5% of it attributed to iron chelation therapy and 33.2% attributed to blood transfusion [2]. Bone marrow transplant (BMT) is the only established cure for thalassaemia at present.

Preoperative testing in elective surgery: Is it really cost effective?

Introduction: During preoperative preparation, patients undergo investigations to detect asymptomatic diseases. The probability of finding significant abnormalities on such routine investigations is small, and these investigations unnecessarily increase costs of perioperative care. We evaluated current practices, compliance with national guidelines and costs of preoperative investigations at the National Hospital of Sri Lanka (NHSL). Materials and Methods: Patients undergoing elective surgery at the general surgical units of the NHSL from June to August 2010 were included in this study. The National Guidelines on Preoperative Investigations were the standard of assessment. Data on preoperative investigations were collected using an expert-validated pretested interviewer-administered questionnaire. Results: Sample size was 2,061 patients. Mean age of the patients was 46.7±15.8 years; males constituted 54.2% of the study population. Majority of the patients were ASA-I (68.5%) and surgical grade II (62.0%). Request for chest X-ray and prothrombin time / international normalized ratio least conformed to the guidelines. Only fasting blood sugar / random blood sugar demonstrated ‘good’ compliance (>70%) to the guidelines. An ‘acceptable’ compliance (50%-70%) was seen for electrocardiogram, blood grouping and full blood count. All other investigations demonstrated ‘poor’ compliance (<50%) with the guidelines. The total excess cost incurred due to non-recommended investigations during the study period of 3 months was Sri Lankan Rupees (LKR.) 1,324,860 to 2,044,210 (per patient LKR. 642.82-991.85). Intern house officers (IHOs) were involved in the planning of preoperative investigations in 2,001 patients (97.1%), followed by medical officeranesthesia / registrar-anesthesia (n=1,625; 78.8%), surgical registrars (n=190; 9.2%), consultant (n=70; 3.4%), senior registrar (n=46; 2.2%) and senior house officers (n=22; 1.1%). Non-recommended investigations were requested mostly by the IHOs and medical officer–anesthesia / registrar-anesthesia. Conclusions: Unnecessary preoperative investigations are common at our institution, leading to substantially excessive costs. There is ample opportunity to rationalize practices and reduce expenditure.