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While managing Sepsis central line should be placed and used only for venous access

Assess patient frequently, screening and initiating early treatment is essential – Prof. Roman Jaeschke Antimicrobial Resistance is increasing, expensive to treat and LMICs will be affected the most – Prof. Timothy Walsh

ISLAMABAD: While managing Sepsis the patient should be assessed frequently, screening and early initiation of treatment is essential. Work out how much fluids have to be used while rescue fluids can be administered at any time. Liberal and appropriate use of fluids can reduce mortality by 14%. Central line should be placed and used only for venous access. This was stated by prof. Roman Jaeschke from McMaster University Canada. He was making a presentation on “ Sepsis- what is old, What is new and What is crucial to know” in the third plenary session of International Medical Conference organized by Pakistan Society of Internal Medicine held here from March 25th to 28th 2024. This session was chaired by Prof. Muhammad Umar Vice Chancellor of Rawalpindi Medical University alongwith other colleagues from Pakistan.

He started his presentation by discussing the differences between the strong and weak recommendations for management of Sepsis. He also shared the Surviving Sepsis Campaign Guidelines. It lays emphasis on screening and early treatment of infections. He also discussed in detail the fluids hemodynamics management and additional therapies. Sepsis relates to life threatening organ dysfunction caused by host response to infections. The management strategy should outweigh risk with benefits. He then discussed how to monitor response to treatment. He further stated that treating physicians must stay on the bedside of the patient which matters a lot and any delay in initiating appropriate treatment increased mortality, he remarked.

Prof. Timothy Walsh from Oxford University UK was the next speaker who discussed “Managing drug resistant infections- a solvable yet Unsolvable Crisis”. He pointed out that when bacteria develops resistance, there is more bacteria than human cells. Bacteria spreads across many sectors and it multiplies every twenty minutes in one hour. Antimicrobial Resistance, he stated, is increasing and Low Middle Income Countries (LMICs) will be affected the most. Unfortunately there is no vaccine for AMR while for Covid19 pandemic we had a vaccine, Covid can be diagnosed quickly but this is not the case with AMR. Its diagnosis is very expensive and we mostly rely in clinical outcome. United Nations, he opined can help in diagnostic access by providing sustainable funding while access to antibiotics was extremely important. He laid stress on prevention of infection, its control, education, improving sewerage and sanitation.

Earlier Prof. John Kolbe President of International Society of Internal Medicine from Auckland discussed Update on Management of Chronic Obstructive Pulmonary Disease (COPD). He also referred to non-pharmacological therapy and the role of ICS. He emphasized the importance of LTOT which he stated reduce mortality. Effective measures and pulmonary rehabilitation leads in good improvement in exercise capacity. He also referred to LABAS and LAMAS used in COPD besides discussing the advantages of once daily and twice daily therapy. COPD is not a contraindication for the use of beta blockers while there are no good indications for widespread use of ICS in COPD. It can have some side effects like pneumonia. Slow initiation of ICS can be possible. Bronchodilator therapy has priority while there is limited role of ICS, he remarked.

Prof. James Douketis from McMaster University Canada discussed Top-5 developments in Thrombosis which the Internists need to Know. Discussing antithrombotic management he pointed out that new drugs are safer than old drugs. He also discussed the importance of rescue thrombolytic therapy. Routine use of thrombolysis is not recommended. He also referred to thrombolytic therapy for DVT, anti-coagulant related bleeding, post bleeding management. One can restart anticoagulants and reduce the risk of thrombosis. It does reduce mortality but there is risk of bleeding, and stroke. Low dose DOAC is best, he added.

Plenary Session-II

Prof. Faraz Mir was the first speaker in the second plenary session who discussed resistant hypertension. His presentation was based on a few case histories. One of the important cause of resistant hypertension he pointed out is non-adherence to medications. Other causes include inaccurate blood pressure measurement, white coat hypertension. On ambulatory blood pressure monitoring, almost 30% patients have normal blood pressure. He also referred to pseudo hypertension. In case of secondary hypertension one must identify the cause of hypertension, life style modifications do make a difference. No smoking, he opined was a pre-requisite. Now device therapies are also available in developed countries but they are very expensive, he remarked.

Dr. Umar Farooq from Penne State Health from United States made a presentation on diabetic nephropathy. In United States, almost 40% patients eventually suffer from chronic kidney disease. There are 326 million people in USA who suffer from diabetes mellitus which is 10% of the population. He then referred to major trials of kidney protective therapies and highlighted the importance, safety and efficacy of SGLT2 Inhibitors which are good, safe and very effective. Diabetologists started using SGLT2 Inhibitors but now cardiologists, nephrologists and Hepatologist are also using these agents. Referring to Fire and Forget treatment strategies he mentioned weight loss, personalized combination therapy. Use of ACE Inhibitors, Aspirin, Diet therapy, blood pressure control, cholesterol treatment, and use of Vitamin-D, Exercise and GLPI-RA are all effective and useful.

Dr. S. P. Chan from University of Malaysia discussed the importance of Glycemic control: Insight from Trials including COVTs. She pointed out that there are 537 million people suffering from diabetes in the world of which 90% are suffering from Type-2 diabetes and 90% of these are in South Asia. While managing diabetes one must remember the risk and benefits of the treatment strategies. She laid emphasis on holistic person centered T2DM management. It includes weight control, Glycemic management, and renal protection. High HbAIc has higher chances of getting myocardial infarction and 1% increase in HbAIc results in 18% increase in myocardial infarction. Reduction in HbAIc leads to reduction of all complications tremendously. UKPDS had showed benefits of good glucose control. Hyperglycemia leads to numerous complications and it is essential to reduce all complications, she remarked.

Prof. Aftab Mohsin in his presentation discussed approach to chronic venous disease. All T2DM patients, he said, should be put on SGLT2 inhibitors. Life style modifications is important and vanoactive drugs have a role which is accepted. One of the participants remarked that in United States they are not used as cost is a problem and we have to justify its use.

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