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Purpose: Uncertainties remain about the safety and efficacy of therapies for managing intracranial hypertension in acute brain injured (ABI) patients. This study aims to describe the therapeutical approaches used in ABI, with/without intracranial pressure (ICP) monitoring, among different pathologies and across different countries, and their association with sixmonths mortality and neurological outcome. Methods: A preplanned subanalysis of the SYNAPSE-ICU study, a multicentre, prospective, international, observational cohort study, describing the ICP treatment, graded according to Therapy Intensity Level (TIL) scale, in patients with ABI during the first week of intensive care unit (ICU) admission. Results: 2320 patients were included in the analysis. The median age was 55 (I-III quartiles = 39-69) years, and 800 (34.5%) were female. During the first week from ICU admission, no-basic TIL was used in 382 (16.5%) patients, mild-moderate in 1643 (70.8%), and extreme in 295 cases (eTIL, 12.7%). Patients who received eTIL were younger (median age 49 (I-III quartiles = 35-62) vs 56 (40-69) years, p

Background: Epidemiological data on critically ill patients is crucial for understanding resource utilisation, gaps in quality of care and for supporting surveillance of endemic or emerging diseases. We report the epidemiology of critically ill patients from 17 intensive care units (ICUs) in Nepal using an established and standardised ICU registry. Methods: The ICU registry data is collected prospectively and includes data on case mix, severity, organ support and outcomes. We conducted a retrospective observational study with all adult (≥18 years) critically ill patients admitted to 17 ICUs in Nepal between September 2019 and September 2022. We report on case mix, treatment received, severity of illness, standardised mortality rates (SMR), discharge outcomes and ICU service activity. Descriptive statistics were used to report the findings. Results: Of the 18603 unique admissions, 14% were operative, with 35% emergency surgeries. Patients’ median age was 57 (IQR 40-71) and 59% were male. Hypertension and diabetes were common comorbidities and pneumonia accounted for 26% of all admissions. During the ICU stay, 39% of patients received mechanical ventilation, 29% received vasoactive medication and 10% received renal replacement therapy. The median predicted risk of death was 0.1 (IQR 0.1-0.3) using APACHE II and 0.2 (IQR 0.1-0.4) using eTropICS. The median SMR was 0.7 (IQR 0.5-0.8) and 0.8 (IQR 0.6-1.4) using eTropICS and APACHE II, respectively. Median length of stay was 4 days (IQR 2-7). Eighteen percent died in the ICU; of those alive at discharge, 12% went home, 84% went to another department and 3% went to another hospital. COVID-19 was the most common notifiable disease reported (12% of all admissions). Median ICU turnover was 9% (IQR 6-14) with bed capacity ranging from 43-278. Conclusions: These findings should guide forecasting and service planning to ensure ICUs can optimally care for critically ill patients in Nepal.

Background and Aims: Use of point-of-care ultrasound (POCUS) in acute care setting has rapidly increased and has potentials to guide patient management. This survey study aims to explore the usefulness of a one-day workshop and to elicit the perceived barriers for effective use of POCUS. Methods: A total of 169 doctors who had attended one day Acute Care Ultrasound workshop were approached through email. Online link to access the survey created using Google forms was sent. The survey contained questions related to the details about the participants, feedback about the workshop, whether the workshop has helped to change the practice of the participants, availability of ultrasound machine during the daily practice and the perceived barriers for use of POCUS. Results: A total of 41 responses were obtained. Majority of the participants had anaesthesiology as the base specialty followed by general practice. Most of them had ICU as their predominant working place, followed by emergency room and operating room. The workshop was found to be helpful by most of the participants. Majority of the participants (20 participants; 49%) had ultrasound machine sometimes available during their daily practice. Only 20% (8 participants) had ultrasound machine always available during their clinical practice. Similarly, 46% (19 participants) considered lack of access to ultrasound machine as a barrier for application of POCUS. Significant number of participants considered lack of supervision and guidance (18 participants; 44%) and lack of knowledge and skills (13 participants; 32%) as the barriers. Conclusions: Majority of the participants found the one-day workshop helpful. Doctors from various specialty, working in acute care setting had participated in the survey. Limited access to ultrasound machine, together with lack of adequate knowledge and skills were perceived as major barriers for effective use of point-of-care ultrasound.

Introduction: Distal radius fractures are one of the commonest fractures and more commonly involve children and elderly. Analgesia during reduction are determined by safety, simplicity, effectiveness and costs. The objective of this study is to evaluate the effectiveness of the Hematoma Block (HB) for reduction in distal forearm fractures in a developing country like Nepal. Methods: The study design was double blind randomized control trial performed at tertiary care hospital from July 2016 to August 2017. The patients having radiologically confirmed distal forearm fractures less than 96 hours old in 46 males and 54 females included after obtaining informed consent. 50 patients receiving Brachial Plexus Block (BPB group), and 50 patients receiving HB group during reduction of distal forearm fractures were initially allotted in two arms of randomized group. Pain measured by Visual Analogue Scale (VAS) was recorded before, during, and after reduction. Results: The study showed that HB with (mean ± SD) a VAS score of 2.08 ± 0.85 was as effective as BPB with a VAS of 1.7 ± 0.64 in terms of producing analgesia ( p=0.013), with the advantage of no motor paralysis and a significantly higher reduction rate, odds 3.45, 95% CI 1.52 – 7.85, p = 0.0013. 1/50 patients in brachial plexus block had bronchospasm needing intubation and ICU care where as 1/50 patient with hematoma block and infection which needed incision drainage and external fixation for complete healing. Conclusions: “The Hematoma Block” is to be encouraged in our set up for the reduction of the distal forearm fractures. The technique may be used in those fractures like isolated ulna fractures, minially displaced tibial fractures, fracture fibula where local anesthesia can be easily infiltrated percutaneously The study may be beneficial in managing such fractures and hence, it will help change in therapeutic policies comparing other modalities.

Introduction Severe sepsis and septic shock is a major cause of morbidity and mortality. The burden is higher and the outcome is dismal in the low and middle income countries. Objective This study aims to evaluate the knowledge about severe sepsis and septic shock among the medical officers of emergency department and intensive care unit in Nepal. It is a cross-sectional survey study. Methodology The medical officers working in emergency department and intensive care unit were asked to fill up the survey questionnaire, which contained the questions related to the demographics of the participant, about the knowledge of sepsis and the hindrances behind the effective management of septic patients. The percentage of correct answers for each question and average correct response for all the questions were analyzed. Results Seventy medical officers from twenty-four hospitals across the country were enrolled in the study. Among them, 39 were working in the emergency department and 31 were working in the intensive care unit. For the individual questions, the percentage of correct answers varied from 8.57% to 82.86% (average 48.16%). As per the response of the participants, lack of knowledge about sepsis and management guidelines, lack of experience for management of sepsis and lack of investigation facilities were considered to be the major barriers for effective management of septic patients. Conclusions Knowledge and understanding about severe sepsis and septic shock among the medical officers of emergency department and intensive care unit in Nepal is sub-optimal. To improve the outcome of septic patients, efforts should be made to increase the understanding among these first-line health care workers by implementing regular and mandatory training programs. Birat Journal of Health Sciences 2016 1(1): 47-50

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Background: Epidermal inclusion cysts very rarely occur in the midline in the area of the anterior fontanelle. Case Description: We report the second case of epidermal inclusion cysts in the midline in the area of the anterior fontanelle in world literature of a 7-month female infant who presented with a slow-growing soft mass located in the midline over the vertex of the head. Conclusion: These lesions with clear contents can have all the features of encephalocele on clinical examination, and imaging will show the exact location, but histopathology will confirm the diagnosis.

Ganglioneuroma is a rare benign tumor, usually seen in children and young adults, arising in the central nervous system. Ganglioneuroma of the mesentery is extremely rare; only one case has been recorded. We report the second case of a primary mesentery ganglioneuroma. The patient underwent surgical intervention for diagnostic and therapeutic purposes.