SummaryHypertonic saline has been in clinical use for many decades. Its osmotic and volumeexpanding properties make it theoretically useful for a number of indications in critical care. This literature review evaluates the use of hypertonic saline in critical care. The putative mechanism of action is presented, followed by a narrative review of its clinical usefulness in critical care. The review was conducted using the Scottish Intercollegiate Guidelines Network method for the review of cohort studies, randomised-controlled trials and meta-analyses. The review focuses specifically on blood pressure restoration and outcome benefit in both haemorrhagic and non-haemorrhagic shock, and the management of raised intracranial pressure. Issues of clinical improvement and outcome benefit are addressed. Hypertonic saline solutions are effective for blood pressure restoration in haemorrhagic, but not other, types of shock. There is no survival benefit with the use of hypertonic saline solutions in shock. Hypertonic saline solutions are effective at reducing intracranial pressure in conditions causing acute intracranial hypertension. There is no survival or outcome benefit with the use of hypertonic saline solutions for raised intracranial pressure. Recommendations for clinical use and future directions of clinical research are presented. . Experimental work on compartmental fluid shifts in animals [3] confirmed hypertonic saline produced haemodynamic changes and its use in many different clinical settings has followed. In 1980, de Fillipe reported almost miraculous recovery from near-fatal haemorrhagic shock in 11 patients [4]. This was thought to be due to osmotic fluid shifts, and led to a resurgence of interest in the clinical use of hypertonic saline. Subsequent studies have demonstrated that the mechanism of action of hypertonic solutions is due to more than just changes in serum osmolality [5,6]. Despite further trials, clinical use of hypertonic saline solutions remains inconsistent and few clinical guidelines exist. Various concentrations of hypertonic saline and combinations with colloids have been used in clinical studies. Concerns persist about the safety of hypertonic solutions in critically ill patients as acute hyperosmolar states have been reported to cause harm. Currently the primary clinical areas of use are the management of intracranial hypertension and shock.The purpose of this review is to focus on clinically relevant aspects of the use of intravenous hypertonic saline. Specifically, three areas will be addressed: 1 Does intravenous hypertonic saline increase blood pressure and survival in hypotensive states? 2 Does intravenous hypertonic saline reduce intracranial pressure and improve outcome for patients with intracranial hypertension? Anaesthesia, 2009Anaesthesia, , 64, pages 990-1003Anaesthesia, doi:10.1111Anaesthesia, /j.1365Anaesthesia, -2044Anaesthesia, .2009.05986. x ...........................................................................................................................

In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.

Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.

We compared the propofol dose causing loss of verbal response and suppression of bispectral index to 50, between 50 white and 50 black patients, aged 18-65 years. Propofol was administered at 40 mg.kg )1 .h )1 and reduced to 8 mg.kg.h )1 when bispectral index fell to 50. We recorded heart rate and mean arterial pressure for 15 min in total and calculated, for this period, maximal percentage change from baseline for each. A statistician, blinded to patient ethnicity, found mean (SD) propofol dose for loss of verbal response in white and black patients to be 1.41 (0.37) mg.kg change in heart rate were 14.1 (12.6) % and 7.5 (14.0) % (p = 0.015). Other differences were non-significant. The dose of propofol required for loss of verbal response, but not for suppression of bispectral index to 50, is lower in black than in white patients. In the last decade it has been suggested that ethnicity may affect the clinical response to general anaesthetics [1-4], with Caucasian subjects generally shown to be less susceptible to the anaesthetic effects of propofol than other races [1][2][3]. To date, however, the effect of ethnicity on the induction dose of propofol has not been fully investigated. In our earlier study on anxiety and propofol induction [5], we used multivariate analysis to investigate factors independently predictive of propofol dose requirement for loss of verbal response. In doing so, we established that white ethnicity was associated with greater propofol dose requirement than other ethnic groups.To investigate this incidental finding further, we studied a new group of patients using a study design better suited to address specifically the issue of ethnicity. Our aim was to determine whether the induction dose of propofol differs between British patients describing themselves as white and black. Our null hypothesis was that ethnicity does not affect the dose of propofol required to produce loss of verbal response. We also sought to establish whether the initial cardiovascular characteristics of propofol anaesthesia differ between white and black patients. MethodsWith Research Ethics Committee approval and written informed consent, we recruited 269 patients of ASA physical status 1-2, aged 18-65 years, scheduled for surgery under general anaesthesia. We did not study patients who were of neither white nor black ⁄ black

Background As trauma systems mature, they are expected to improve patient care, reduce in-hospital complications and optimize outcomes. Qatar has a single trauma center, at the Hamad General Hospital, which serves as the hub for the trauma system that was verified as a level 1 trauma system by the Accreditation Canada International Distinction program in 2014. We hypothesized that this international accreditation was a major step, in the maturation process of the Qatar trauma system, that has positively impacted patient care, reduced complications and improved outcomes of trauma patients in such a rapidly developing country. Methods A retrospective analysis of data was conducted for all trauma patients who were admitted between 2010 and 2018. Data were obtained from the level 1 trauma center registry at Hamad Medical Corporation. Patients were divided into Group 1- pre-accreditation (admitted from January 2010 to October 2014) and Group 2- post-accreditation (admitted from November 2014 to December 2018). Patients’ characteristics and in-hospital outcomes were analyzed and compared. Data included patients’ demographics; injury types, mechanism and injury severity scores, interventions, hospital stay, complications and mortality (pre-hospital and in-hospital). Time series analysis for mortality was performed using expert modeler. Results Data from a total of 15,864 patients was collected and analyzed. Group 2 patients had more severe injuries in comparison to Group 1 (p<0.05). However, Group 2, had a lower complication rate (ventilator associated pneumonia (VAP)) and a shorter mean hospital length of stay (p<0.05). The overall mortality was 8%. In Group 2; the pre-hospital mortality was higher (52% vs. 41%, p = 0.001), while in-hospital mortality was lower (48% vs. 59%) compared to Group 1 (p = 0.001). Conclusions The international recognition and accreditation of the trauma center in 2014 was the key factor in the maturation of the trauma system that improved the in-hospital outcomes. Accreditation also brought other benefits including a reduction in VAP and hospital length of stay. However, further studies are required to explore the maturation process of all individual components of the trauma system including the prehospital setting.