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BackgroundInfections caused by multi-drug resistant gram-negative bacterial infections are the principle threats to the critically ill patients of intensive care units. Increasing reports of these infections from the Nepalese intensive care unit underline the clinical importance of these pathogens. However, the impact of these infections on the patient’s clinical outcome has not yet been clearly evaluated. The objective of our study was to determine the incidence and associated clinical outcome of multi-drug resistant gram-negative bacterial infections in intensive care unit from a tertiary care center of Nepal.MethodsA prospective cohort study was conducted among adult patients admitted in intensive care unit of B. P Koirala Institute of Health Sciences from July to December 2017. Patients infected with multi-drug resistant gram-negative bacteria, non-multi-drug resistant gram-negative bacteria and those without infection were included. Identification of gram-negative bacteria and their antibiotic susceptibility pattern was performed with standard microbiological methods. Demographic, clinical profiles and outcomes (in-hospital-mortality, intensive care unit and hospital length of stay) were documented.ResultsThe incidence rate of multi-drug resistant gram-negative bacteria infections was 47 per 100 admitted patients (64/137) with 128 episodes. Acinetobacter species (41%, 52/128) was the commonest followed by Klebsiella pneumoniae (28%, 36/128) and Pseudomonas spp (21%, 27/128). Patients with multi-drug resistant gram-negative bacteria in comparison to non-multi-drug resistant gram-negative bacteria had high healthcare-associated infections (95%, 61/64 versus 20%, 2/10; p = < 0.001). In-hospital-mortality was 38% (24/64), 20% (2/10) and 10% (4/41) in multi-drug resistant, non-multi-drug resistant and uninfected group respectively (p = 0.007). After adjustment for independent risk factors, compared to uninfected patients, the odds ratio (CI) for in-hospital-mortality in multi-drug resistant and non-multi-drug resistant group was (4.7[1.4–15.5], p = 0.01) and 2.60 [0.38–17.8], p = 0.32) respectively. Multi-drug resistant patients also had longer intensive care unit and hospital stay, however, it was statistically insignificant.ConclusionThe incidence of multi-drug resistant gram-negative bacterial infections was remarkably high in our intensive care unit and showed a significant association with healthcare-associated infections and in-hospital-mortality.

Over the last decade, the number of reported instances of lost guide wires during central venous catheterization has increased rapidly. Unsupervised or improperly supervised insertions of the central catheters by trainees, distractions during insertions, and high workload are the main risk factors. A retained guide wire increases the risk and cost of additional diagnostic and therapeutic interventions, as well as imposing many minor-to-serious life-threatening complications. Continuing education along with simulator-based skill development, vigilant supervision, and a shared workload during out of hours working are likely to prevent such occurrences.

We assessed if the addition of melatonin to alprazolam has superior premedication effects compared to either drug alone. A prospective, double blind placebo controlled trial randomly assigned 80 adult patients (ASA 1&2) with a Visual Analogue Score (VAS) for anxiety ≥3 to receive a tablet containing a combination of alprazolam 0.5 mg and melatonin 3 mg, alprazolam 0.5 mg, melatonin 3 mg, or placebo orally 90 min before a standard anesthetic. Primary end points were change in anxiety and sedation score at 15, 30, and 60 min after premedication, and number of patients with loss of memory for the five pictures shown at various time points when assessed after 24 h. One-way ANOVA, Friedman repeated measures analysis of variance, Kruskal Wallis and chi square tests were used as relevant. Combination drug produced the maximum reduction in anxiety VAS (3 (1.0–4.3)) from baseline at 60 min (P < 0.05). Sedation scores at various time points and number of patients not recognizing the picture shown at 60 min after premedication were comparable between combination drug and alprazolam alone. Addition of melatonin to alprazolam had superior anxiolysis compared with either drugs alone or placebo. Adding melatonin neither worsened sedation score nor the amnesic effect of alprazolam alone. This study was registered, approved, and released from ClinicalTrials.gov. Identifier number: NCT01486615.

Introduction: The study compared spinal anesthesia using intrathecal hyperbaric bupivacaine between height and weight adjusted dose and fi xed dose during caesarean section. Methods: A hundred parturients, who had given their consent and were scheduled for elective caesarean section under spinal anesthesia, were randomly assigned into two groups. We adjusted the intrathecal dose of heavy bupivacaine (0.5 %) according to the height and weight of patients (Group AD) from Harten’s dose chart developed from the Caucasian parturients and the fi xed dose (2.2 ml) was used in Group FD patients. Keeping the observer blinded to the study groups, the onset time to sensory block up to T5, haemodynamic changes, side effects, and fetal outcome were observed. Results: The median onset time of spinal block in Group FD was faster than in Group AD (6 min vs. 4 min; p = 0.01). The spinal block level extended above T3 level in a signifi cantly (p < 0.05) larger number of patients 12 (24 %) in Group FD than in one (2 %) patient in Group AD. A signifi cantly (p < 0.05) larger number of patients, 32, (64 %) in Group FD had hypotension than in 15 (30 %) patients in Group AD. The lowest recorded SAP (101 ± 6 mm Hg) in Group AD was higher than in Group FD (96 ± 6.7 mm Hg). Nausea and vomiting were more pronounced in Group FD patients. Conclusions: The bupivacaine dose was signifi cantly reduced on its dose adjustment for the body weight and height of patients for cesearean section. This adjusted-dose use suitably restricted spinal block level for cesarean section with a distinct advantage of less hypotension and with a similar neonatal outcome as fi xed compared with the dose use. keywords: caesarean section; low-dose hyperbaric bupivacaine; spinal anesthesia.