Only 20-25% Hospitals in Karachi have proper ICUs and 50% have monitoring facilities Prof.Tipu Sultan

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Clinical Proceedings of SURGICON 2013

Only 20-25% Hospitals in Karachi have proper ICUs
and 50% have monitoring facilities Prof.Tipu Sultan

Nutritional support is proactive therapy in critically ill patients which
reduces complications, improves patient outcome-Dr. Naheed Elahi

About 50% of ICU patients suffer from moderate to severe pain and
effective analgesia is integral in ICU management - Dr. Gohar Afshan

KARACHI: Prof. S. Tipu Sultan an eminent anesthesiologist and Councilor of CPSP who established the Surgical Intensive Care Unit at Civil Hospital Karachi many years ago which provides absolutely free treatment facilities delivered an invited talk on “Present scenario of critical care in Karachi” during the recently held SURGICON 2013 held at CPSP Karachi. Critical care was defined as monitoring of each organ, correct of organ unction, achieving physiological parameters and management of total body functions to save life. For a population of twenty million Karachi, Prof. Tipu Sultan said has one hundred thirty four private and public hospitals with total bed strength of 21,170. Of this public sector hospital beds account for 11,550 while private sector has 9,520 hospital beds. This excludes small maternity homes.
There are different types of Intensive Care Units which include medical, paediatric and neonatal ICUs while teaching hospitals have multidisciplinary ICUs. Total ICU beds in Karachi are 480. Only 15-20% of these ICUs have purpose built facilities, teaching facilities for staff and residents are available in 1-2%.Some of these healthcare facilities also present High Dependency Units at ICUs. Only 20-25% have proper ICU Beds. Again only 40-50% of these ICUs have working ventilators with new latest equipment, 30% have supporting equipment but just 5-10% have arrangements for In-House drugs delivery otherwise most of these ICUs ask the patient attendants to arrange for drugs. At times drugs are changed quite frequently and the patients have to bear this loss. Again 16-20% of these ICUs have dedicated nursing staff. In some of these ICUs one trained nurse looks after three to four patients. Very few of these ICUs have trained dedicated doctors while most of the hospitals have untrained staff working in the Intensive Care Units. Only 7-11% of these ICUs have dedicated consultant cover.
Giving details about the management protocols, Prof.Tipu Sultan said that most of these patients are under primary care physicians, surgeons and gynaecologists. No one was willing to talk when asked who is responsible and accountable for these patients or who makes decisions regarding admission and discharge of these patients. Some of these ICUs charge forty to fifty thousand per day. Some of these hospitals have acquired refurbished ventilators and have no proper infection control policies. In many cases management or hospital owner are keen to ensure that no ventilator is idle hence they put patients on ventilation even if they do not require. Majority of the ICUs have just MBBS doctors looking after these seriously ill patients. In private hospitals ventilation, full management with necessary tests costs about fifty to eighty thousand rupees per day but in case the patient is not on ventilation and no on multiple managements, the charges per day could be thirty thousand rupees. Only four to five hospitals in Karachi provide ICU facilities free of cost and they manage it through donations. He concluded his presentation stating that there is an acute shortage of critical care beds i.e. ICUs, Neonatal ICU, it is very costly. When the hospital management finds out abou8t these unrealistic costs, they compromise on quality management. Most places have non-trained healthcare staff, most have o dedicated staff. There is no financial incentive to staff working in ICUs and it is a pathetic story as regards doctors, nurses and technicians working in these Intensive Care Units.
Dr. Naheed Elahi talked about critical care management at ICU in a Dubai Hospital. She discussed the importance of nutrition in management of critical ill patients. At times the question arises can we feed and why should we feed? There is worst outcome in underfed patients. She opined that early feeding is better. Nutritional support is proactive therapy which reduces complications besides ensuring favorable outcome. She also mentioned about practice guidelines and said that probiotics became popular in 2013, TPN reduced mortality rate but infections rate remains high. Enteral nutrition may be a preferred method of nutritional support in critically ill but we do not want to starve our patients. Low infections rate ensures better wound healing with eternal nutrition. In some patients TPN may be needed. Probiotics are now used for E nutrition and they do have effects on infections. She also talked about nutritional goals for stressed ICU patients feeding levels of various calories. Stress with hypoglycemia increased mortality. ICU patients do become hypoglycemic irrespective of the fact whether they are diabetic or non-diabetic. Early Enteral nutrition is better and it also takes care of hypoglycemia, she added.
Dr. Gohar Afshan from Aga Khan University Hospital was the next speaker and she talked about pain management in ICU. She discussed at length prevalence, etiology, pathology of pain and assessment strategies besides current standard treatments. She pointed out that about one third of patients are on ventilators and they suffer from acute pain. Prevalence of pain is quite high. Pain could be due to trauma, burns, catheters and drains, painful joints. ICU pain could also be due to underlying disease and iatrogenic therapies. Patients can suffer from somatic pain, neuropathic pain, visceral pain or complex mixed pain. Most patients in ICU complain of complex mixed pain and we need to manage them efficiently. Almost 50% of ICU patients suffer from moderate to sever pain and if it remains untreated, it becomes chronic pain. These patients are often under treated because of various misconceptions. There are errors in pain assessment, traditional emphasis on PRN. Sleeping patients may not have much pain and then there are fears of side effects of pain drugs. Almost 40% of ICU patients are delirious, they cannot communicate and need multidisciplinary management approach. She also highlighted the benefits of pain relief in ICUs. It is difficult to observe the severity of pain in those patients who are on ventilator or those who cannot communicate. She then discussed how to use the Critical Care Pain Observation Tool, availability of drugs, economic factors and new technologies. She was of the view that there is no use in advocating a technology which is beyond our resources. Appropriate use of existing facilities, technologies, and analgesics should be ensured avoiding misuse of the facilities. Uncontrolled pain will make the patient condition worse and it becomes difficult for the patient to come to normal functions. She advocated maximizing analgesia to reduce pain. Start with strong opioids by local and then go to analgesics, NSAIDs. Opioids remain first line treatment for ICU patients. Gabapentine is also useful and effective. She concluded her presentation by stating that effective analgesia is integral in ICU management. Pain assessment is not satisfactory, regular pain assessment and better understanding of pain management will improve outcome. Prof. Sadiqa Aftab from Civil Hospital Karachi discussed in detail the Sepsis management guidelines.