Marija Vukoja

A Survey on Critical Care Resources and Practices in Low- and Middle-Income Countries

BACKGROUND Timely and appropriate care is the key to achieving good outcomes in acutely ill patients, but the effectiveness of critical care may be limited in resource-limited settings. OBJECTIVES This study sought to understand how to implement best practices in intensive care units (ICU) in low- and middle-income countries (LMIC) and to develop a point-of-care training and decision-support tool. METHODS An internationally representative group of clinicians performed a 22-item capacity-and-needs assessment survey in a convenience sample of 13 ICU in Eastern Europe (4), Asia (4), Latin America (3), and Africa (2), between April and July 2012. Two ICU were from low-income, 2 from low-middle-income, and 9 from upper-middle-income countries. Clinician respondents were asked about bed capacity, patient characteristics, human resources, available medications and equipment, access to education, and processes of care. RESULTS Thirteen clinicians from each of 13 hospitals (1 per ICU) responded. Surveyed hospitals had median of 560 (interquartile range [IQR]: 232, 1,200) beds. ICU had a median of 9 (IQR: 7, 12) beds and treated 40 (IQR: 20, 67) patients per month. Many ICU had ≥ 1 staff member with some formal critical care training (n = 9, 69%) or who completed Fundamental Critical Care Support (n = 7, 54%) or Advanced Cardiac Life Support (n = 9, 69%) courses. Only 2 ICU (15%) used any kind of checklists for acute resuscitation. Ten (77%) ICU listed lack of trained staff as the most important barrier to improving the care and outcomes of critically ill patients. CONCLUSIONS In a convenience sample of 13 ICU from LMIC, specialty-trained staff and standardized processes of care such as checklists are frequently lacking. ICU needs-assessment evaluations should be expanded in LMIC as a global priority, with the goal of creating and evaluating context-appropriate checklists for ICU best practices.

Checklist for early recognition and treatment of acute illness: International collaboration to improve critical care practice.

Processes to ensure world-wide best-practice for critical care delivery are likely to minimize preventable death, disability and costly complications for any healthcare systems sickest patients, but no large-scale efforts have so far been undertaken towards these goals. The advances in medical informatics and human factors engineering have provided possibility for novel and user-friendly clinical decision support tools that can be applied in a complex and busy hospital setting. To facilitate timely and accurate best-practice delivery in critically ill patients international group of intensive care unit (ICU) physicians and researchers developed a simple decision support tool: Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN). The tool has been refined and tested in high fidelity simulated clinical environment and has been shown to improve performance of clinical providers faced with simulated emergencies. The aim of this international educational intervention is to implement CERTAIN into clinical practice in hospital settings with variable resources (included those in low income countries) and evaluate the impact of the tool on the care processes and patient outcomes. To accomplish our aims, CERTAIN will be uniformly available on either mobile or fixed computing devices (as well as a backup paper version) and applied in a standardized manner in the ICUs of diverse hospitals. To ensure the effectiveness of the proposed intervention, access to CERTAIN is coupled with structured training of bedside ICU providers.

Acute Respiratory Distress Syndrome: The Prognostic Value of Ventilatory Ratio—A Simple Bedside Tool to Monitor Ventilatory Efficiency

investigate the direct impact of IH on working memory in healthy young adults. This study demonstrated that shortterm exposure to IH per se (i.e., without the confounding influence of sleep fragmentation and medical comorbidities) can negatively impact performance on spatial working memory tasks, even in healthy young adults. Previous studies did not observe this effect possibly due to the lack of a control group (i.e., participants not exposed to IH) (12, 13). These studies did not control for a possible learning effect on n-back task performance. It is also important to note that only verbal n-back tasks were used in these previous studies and no significant effects of IH on verbal tasks were observed in the present study. Finally, Thomas and colleagues (12) exposed participants to continuous hypoxia, which has been shown to have different physiological effects than IH, a closer approximation of OSA (14). These results provide the basis for future studies. The results are limited by the small sample size due to the intensive data collection required for these studies. Future studies should attempt to replicate these results with a larger number of participants. The replication of these findings in an older population would also be important as OSA occurs more frequently in older adults. In fact, it is hypothesized that a larger detrimental effect of IH on working memory function would be observed in older participants due to the age-related decline in brain resilience. Although these findings are preliminary, the significant shortterm effects of acute IH exposure on spatial working memory raise the possibility of more significant effects of chronic IH exposure on working memory function in patients with OSA. Early treatment of sleep apneamay be important tominimize potential long-term effects on working memory and other cognitive functions. Recent studies also suggest that some interventions such as exercise training could be proven useful in minimizing cognitive dysfunctions and improving selected aspects of daytime functioning in patients with OSA (15, 16).

Correlation between the Wells score and the Quanadli index in patients with pulmonary embolism

Determining clinical probability of pulmonary embolism (PE) with Wells scoring system is the first step towards diagnosis of PE. Definitive diagnosis of PE is confirmed by computed tomography pulmonary angiography (CTPA).

The Association between the Inflammatory Biomarkers and Left Ventricular Systolic Dysfunction in Patients with Exacerbations of Chronic Obstructive Pulmonary Disease.

Background: Cardiovascular diseases are an important cause of morbidity and mortality in chronic obstructive pulmonary disease patients. The increased inflammatory biomarker levels predict exacerbations and are associated with cardiovascular diseases in stable chronic obstructive pulmonary disease patients but their role in the settings of acute chronic obstructive pulmonary disease exacerbations has not been determined. Aims: To analyse the association between inflammatory biomarkers and heart failure and also to determine the predictors of mortality in patients with exacerbations of chronic obstructive pulmonary disease. Study Design: Prospective observational study. Methods: We analysed 194 patients admitted for acute exacerbation of chronic obstructive pulmonary disease at The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia. In all patients, C-reactive protein, fibrinogen, N-terminal of the pro-hormone brain natriuretic peptide and white blood count were measured and transthoracic echocardiography was performed. Results: There were 119 men (61.3%) and the median age was 69 years (interquartile range 62-74). Left ventricular systolic dysfunction (ejection fraction <50%) was present in 47 (24.2%) subjects. Patients with left ventricular systolic dysfunction had higher C-reactive protein levels (median 100 vs. 31 mg/L, p=0.001) and fibrinogen (median 5 vs. 4 g/L, p=<0.001) compared to those with preserved ejection fraction. The overall hospital mortality was 8.2% (16/178). The levels of C-reactive protein, fibrinogen, N-terminal pro-brain natriuretic peptide and ejection fraction predicted hospital mortality in univariate analysis. After adjusting for age, hypoxemia and C-reactive protein, ejection fraction remained significant predictors of hospital mortality (OR 3.89, 95% CI 1.05-15.8). Conclusion: Nearly a quarter of patients with the exacerbation of chronic obstructive pulmonary disease present with left ventricular systolic dysfunction which may be associated with mortality.

Pneumonia: Features registered in autopsy material.

Background: Despite improvements in clinical practice, pneumonia remains one of the leading causes of death worldwide. Pathologic findings from autopsy reports could provide more precise and valid data on characteristics of pneumonia patients. Methods: We retrospectively reviewed autopsy reports of deceased patients admitted to the Institute for Pulmonary Diseases of Vojvodina in Sremska Kamenica, Serbia, between 1994 and 2003. The patients were classified into two groups: group 1 (n = 161) comprised patients in whom pneumonia was the main cause of death, while group 2 (n = 165) consisted of patients in whom pneumonia was confirmed at autopsy but had various different causes of death. Results: From 1776 patients who underwent autopsy 326 (18.3%) were diagnosed with pneumonia. The most common underlying diseases were atherosclerosis (29.4%), chronic obstructive pulmonary disease (COPD) (26.7%), and malignancies (20.2%). Pneumonia was the main cause of death in 161 cases (group 1) while in group 2 major causes of death were heart failure (HF) (26.7%), acute myocardial infarction (AMI) (16.4%), and pulmonary embolism (PE) (10.9%). Multilobar involvement (91% vs.27%), pulmonary effusion (29% vs.14%), and lung abscess (23.6% vs.8.5%) were more frequently found in group 1, compared to group 2. Conclusion: In patients with pneumonia who underwent autopsy most common underlying diseases were atherosclerosis, COPD, and malignancies, while major causes of death were: progression of pneumonia, HF, AMI, and PE.

Treatment of sleep apnoea syndrome

Treatment of patients with sleep disordered breathing and especially sleep apnea syndrome, involves a multidisciplinary approach. In all cases, it is necessary to implement adequate hygiene and diet lifestyle, as a prerequisite for active therapy. Non-invasive ventilation (NIV) is the gold standard for therapy, and it is carried predominantly by internists and pulmonologist. Dentists-orthodontists are involved in cases where a specially designed oral proven applications enable opening the airway in the throat. They are applied on the basis of preliminary estimates of clinical benefit, after the NIV refusal of treatment by patients with normal BMI. Surgical methods are primarily related to ENT interventions on the structures of the soft palate and mouth, with correction of nasal patency, with the aim of solving the mechanical obstruction of air flow. Extensive maxillofacial surgery is performed with significant craniofacial abnormalities and it is very demanding procedure, therefore strictly selective. In severe cases, tracheostomy is an option for emergency treatment of vitally endangered patients resistant to NIV treatment, often with very high BMI. Medical therapy is still inefficient. It is actually more important today to draw attention to the patient what medications should not be used (particularly sedatives), because they can worsen the degree of apnea during sleep and further disrupt the architecture of sleep.

Spontaneous pneumomediastinum: ten years of our experience in diagnosis and outcome

Spontaneous pneumomediastinum (SPM) is a rare clinical condition that may be mild but also dramatic with sudden onset of chest pain and dyspnea accompanied by swelling and subcutaneous crepitations. The objective of this study was to analyze the clinical presentation and outcome of SPM in a specialized pulmonary tertiary care centre over a 10 years year period. In subsequent followup, we received information related to recurrence episodes of SPM by patients or their GPs physicians. Eighteen patients, 15 (83%) men, mean age 24 years (SD ±7.86) were diagnosed with SPM. Predominant symptoms were chest pain and cough (n=11) then dyspnea (n=9). Asthma was the most common predisposing condition (n=12). Pneumomediastinum was present on chest radiograph in 17 cases (94%), and in one case it was detected only by computed tomography. The mean length of hospital stay was 7 days (SD ±4.4 days). All our patients recovered and there were no complications. Recurrent event occurred in one asthma patient, 2 years after the first episode. Although, SPM is usually a self-limiting and benign condition, close monitoring is necessary. Recurrence is rare, but possible, with no evidence that routine monitoring of those patients is needed.