Mahmoud Elbarbary

GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation's direction and strength.

In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. This article addresses GRADEs approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention.

International evidence-based recommendations on ultrasound-guided vascular access

PurposeTo provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access.MethodsAn international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations.ResultsThe recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications.ConclusionsThese definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography.

Objective: To establish evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities. Methods: The Grading of Recommendations, Assessment, Development and Evaluation system was used to determine the strength of recommendations as either strong or conditional/weak and to rank the “levels” of quality of evidence into high (A), moderate (B), or low (C) and thus generating six “grades” of recommendation (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for all questions with clinically relevant outcomes. RAND appropriateness method, incorporating modified Delphi technique, was used in steps of GRADE that required panel judgment and for those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias. The process was conducted independent of industry funding. Results: Twenty-four statements regarding the use of ultrasound were considered—three did not achieve agreement and nine were approved as conditional recommendations (strength class 2). The remaining 12 statements were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence. Key strong recommendations included the use of ultrasonography for ruling-in pleural effusion and assisting its drainage, ascites drainage, ruling-in pneumothorax, central venous cannulation, particularly for internal jugular and femoral sites, and for diagnosis of deep venous thrombosis. Conditional recommendations were given to the use of ultrasound by the intensivist for diagnosis of acalculous cholecystitis, renal failure, and interstitial and parenchymal lung diseases. No recommendations were made regarding static (vs dynamic) ultrasound guidance of vascular access or the use of needle guide devices. Conclusions: There was strong agreement among a large cohort of international experts regarding several recommendations for the use of ultrasound in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients.

Ultrasound for the Anesthesiologists: Present and Future

Ultrasound is a safe, portable, relatively inexpensive, and easily accessible imaging modality, making it a useful diagnostic and monitoring tool in medicine. Anesthesiologists encounter a variety of emergent situations and may benefit from the application of such a rapid and accurate diagnostic tool in their routine practice. This paper reviews current and potential applications of ultrasound in anesthesiology in order to encourage anesthesiologists to learn and use this useful tool as an adjunct to physical examination. Ultrasound-guided peripheral nerve blockade and vascular access represent the most popular ultrasound applications in anesthesiology. Ultrasound has recently started to substitute for CT scans and fluoroscopy in many pain treatment procedures. Although the application of airway ultrasound is still limited, it has a promising future. Lung ultrasound is a well-established field in point-of-care medicine, and it could have a great impact if utilized in our ORs, as it may help in rapid and accurate diagnosis in many emergent situations. Optic nerve sheath diameter (ONSD) measurement and transcranial color coded duplex (TCCD) are relatively new neuroimaging modalities, which assess intracranial pressure and cerebral blood flow. Gastric ultrasound can be used for assessment of gastric content and diagnosis of full stomach. Focused transthoracic (TTE) and transesophageal (TEE) echocardiography facilitate the assessment of left and right ventricular function, cardiac valve abnormalities, and volume status as well as guiding cardiac resuscitation. Thus, there are multiple potential areas where ultrasound can play a significant role in guiding otherwise blind and invasive interventions, diagnosing critical conditions, and assessing for possible anatomic variations that may lead to plan modification. We suggest that ultrasound training should be part of any anesthesiology training program curriculum.

Ultrasound performs better than radiographs

We applaud the British Thoracic Society (BTS) for its efforts to improve patient care through scientific evidence. We thus recognise the recent guidelines on pleural procedures and thoracic ultrasound (TUS) as an important attempt to develop a rational approach to chest sonography.1 However, we are concerned that the BTS has reached conclusions based on a less complete review of TUS. The guidelines state that ‘the utility of thoracic ultrasound for diagnosing a pneumothorax is limited in hospital practice due to the ready availability of chest x-rays (CXR) and conflicting data from published reports’.1 This conclusion appears to be based on a small (but landmark) study of 11 patients from 1986 to 1989, two small studies with only four pneumothoraces in …

Soluble tumor necrosis factor receptor p55 predicts cytokinemia and systemic inflammatory response after cardiopulmonary bypass

ObjectivesTo examine the behavior of soluble tumor necrosis factor (TNF) receptors in circulation before and after cardiopulmonary bypass and the relationship to the development of cytokinemia and acute complications comprising systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). The predictive value of soluble TNF receptor is assessed herein. DesignProspective study comparing prebypass and postbypass levels in patients with and without complications indicative of SIRS and MODS. SettingCardiac surgical intensive care unit in a tertiary care hospital. PatientsA total of 20 pediatric patients who underwent cardiopulmonary bypass during open heart surgery. InterventionsBlood samples were collected from catheters before and 2 hrs and 24 hrs after the onset of bypass. Measurements and Main ResultsWe measured plasma levels of soluble TNF receptors by using enzyme-linked immunosorbent assay in 20 patients before and after cardiopulmonary bypass. Clinical data, including duration of bypass and tests or signs indicative of SIRS/MODS, were collected. Soluble TNF receptor I (p55 sR), significantly increased (2241 ± 312 pg/mL) at 2 hrs after bypass (p < .0005) and remained elevated (2826 ± 695 pg/mL) at 1 day after bypass (p < .005) when compared with prebypass levels (725 ± 130 pg/mL). Patients with the acute complications of SIRS/MODS had a higher ratio of postbypass to prebypass p55 sR levels (5.0-fold, p < .001) when compared with patients with no SIRS/MODS (1.75-fold). Remarkably, before surgery, levels of TNF p55 sR predict both cytokinemia (r = .67 to .73, p < .05) and SIRS/MODS (p < .01). The prebypass levels of TNF p55 sR were consistently higher (range, 1000–1400 pg/mL) in patients who subsequently developed SIRS/MODS than the levels (range, 400–570 pg/mL) in patients who did not develop SIRS/MODS. Hypotension, respiratory dysfunctions, and coagulopathy were particularly more prevailing (p < .005) among the complications that were associated with high prebypass levels of TNF p55 sR. ConclusionsSoluble TNF receptor p55 can be employed as a predictive marker for cytokinemia and the development of SIRS/MODS that may arise from a major insult to the body such as cardiopulmonary bypass.

Trauma in the Pediatric Patient

Pediatric trauma remains a significant burden on health care resources. The impact both physically and emotionally on pediatric patients, their parents, and families and on health care providers can be profound and long lasting. This chapter addresses particularities of pediatric trauma and resuscitation of the traumatized child. The challenges in the assessment and management of the injured child are discussed. Finally, the composition and dynamic function of the pediatric trauma team are reviewed.

Effects of protocol-based management on the post-operative outcome after systemic to pulmonary shunt

Objectives Systemic to pulmonary shunt (commonly known as Modified Blalock-Taussig shunt) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lungs. Based on the most recent risk stratification score, the mortality and morbidity of this procedure is still high especially in neonates and over-shunting patients. We developed and implemented protocol-based management in March 2013 to better standardize the management of these patients. The aim of this study is to evaluate the effects of applying this protocol-based management in our center. Methods We conducted a retrospective cohort study through chart review analysis.We included all children who underwent MBTS from January 2000 till December 2015. We compared the early postoperative outcome of patients operated after the protocol-based management implementation (March 2013 till December 2015) (protocol group) with patients operated before implementing the MBTS protocoled management (control group). Results 197 patients underwent MBTS from January 2000 till December 2015. Of the 197 patients, 25 patients were in the protocol group and 172 patients were in the control group. There was a significant improvement in the postoperative course and less morbidity after protocoled management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, intensive care unit ICU stay and significantly lower postoperative complications in the protocol group. Mortality of the control group versus protocol group (19.3% VS 8%) with Standardized Mortality Ratio (SMR) dropped from 2.27 before protocoled management to 0.94 after protocoled management (protocol group). Conclusion The study suggests that protocoled management of patients with MBTS can improve the postoperative course and early outcome.

5. Effect of protocol-based management for systemic to pulmonary shunt operations

Abstract Type Clinical research. Presentation Type Oral presentation. Introduction Systemic to pulmonary shunt (commonly Modified Blalock-Tausing shunt – MBTS) is a palliative procedure in cyanotic heart diseases to overcome inadequate blood flow to the lung (1). Based on most recent risk stratification STAT score, the average mortality is still high (8.5%) in addition to significant post-operative morbidity especially in the neonatal and over-shunting patients. We developed and implemented protocoled management in March 2013 to better standardize the management of these patients. Aim of this study to evaluate the effect of applying this protocoled management in our center. Methodology We conducted a retrospective Cohort study through chart review analysis of all children who underwent MBTS since year January 2000 till December 2015, We compared the early postoperative outcome of patients operated after the protocol management implementation (March 2013 till December 2015) (group A) with patients operated before implementing the MBTS protocoled management (group B). Results 197 patients underwent MBTS since year 2000 till December 2015, 25 patients after the implementation the protocol management (group A), and 172 patients before the protocol implementation (group B). There was a significant improvement in the postoperative course and less morbidity after protocol management implementation as reflected in ventilation time, reintubation rate, inotropic support duration, and postoperative complications were all significantly lower in (group A). Mortality group A versus group B (15.7% VS 8%). Based on STAT score, the standardized mortality ratio (SMR) dropped from 1.84 before protocol implementation to 0.94 after protocol implementation. Conclusion The study proves that protocol management of patients with MBTS can improve the postoperative course and early outcome.