Study: O2 supplementation not superior to RA in improving UA lactate

According to research presented at the 2018 Annual meeting of the Society for Maternal-Fetal Medicine, room air (RA) is not inferior to O₂ for improving umbilical artery (UA) lactate in patients with Category II fetal heart tracings (FHT) during active labor. According to the authors, approximately two-thirds of women in labor receive O₂ to reverse perceived fetal hypoxemia and to prevent acidosis.    

In a randomized controlled non-inferiority trial conducted from June 2016 to June 2017, the researchers looked at 114 singleton pregnancies ³ 37 weeks with Category II FHT that required intrauterine resuscitation in active labor (³ 6 cm). The participants were randomized to receive either RA or 10L/min O₂ by facemask until delivery. The primary outcome was UA lactate measured by umbilical cord gases collected at delivery. Secondary outcomes were other UA gas components, cesarean delivery for nonreassuring fetal status, and operative vaginal delivery. Noninferiority was declared if the mean difference in lactate between RA and O₂ was < 1.0 mmol/L and analysis was by intention-to-treat.  

Of the 114 patients included in the study, 99 with paired cord gases were included in the intention-to-treat analysis. There were 48 patients who received O₂ and 51 patients who received RA. The researchers found no difference in mean UA lactate between the randomized 0₂ and RA groups (mean [95% CI], O₂ = 3.4 [3.0,3.8] vs RA = 3.5 [3.1, 4.0], P = 0.69). For UA lactate, the mean difference was 0.1 mmol/L (95% CI -0.5, 0.7). The researchers found no differences in other UA gas components, vaginal delivery or nonreassuring fetal status between the groups.

U-Turn: Ministry of Health De-Recognizes PG diplomas offered by CPS, Mumbai

New Delhi: Just a few months after granting recognition to the postgraduate degrees offered by the College of Physicians and Surgeons, Mumbai by including them in the First Schedule of the Indian Medical Council Act, 1956, the Ministry of Health and Family Welfare has now recognized most of the courses offered by CPS. At the same time, it has given recognition to certain Membership and Fellowship courses granted by College of Physicians and Surgeons, Mumbai.

As per the recent gazette, in exercise of the power conferred by sub-section (2) of Section 11 of the Indian Medical Council Act, 1956 (102 of 1956), the Central Government after consulting the Medical Council of India, has made amendments in the First Schedule of the Act and following entries appearing under the main heading ‘College of Physicians and Surgeons, Mumbai’, the heading ‘Recognized Medical Qualifications’, shall be deleted:

S.NO	Course Name	Recognition
1	Diploma in Ophthalmic Medicine & Surgery (DOMS)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
2	Diploma in Dermatology & Venereology (DDV)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
3	Diploma in Anaesthesia (DA)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
4	Diploma in Oto-Rhino-Laryngology (ENT) (DORL)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
5	Diploma in Orthopaedics(DORTHO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
6	Diploma in Psychological Medicine(DPM)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
7	Diploma in Medical Radiology & Electrology(DMRE)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
8	Diploma in Tuberculosis Diseases(TDD)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
9	Diploma in Family Planning(DFP)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
10	Diploma in Public Health(DPH)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
11	Diploma in Transfusion Medicine(DTM)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
12	Diploma in Tropical Medicine & Health (DTMH)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after December 2009.
13	Diploma in Diabetology(DDIAB)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
14	Diploma in General Medicine(DGM)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
15	Diploma in General Surgery(DGS)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
16	Diploma in medical Oncology(DMO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
17	Diploma in Cardiology(DCARD)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
18	Diploma in Minimal Access Surgery (DMAS)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
19	Diploma in Gynaecological Endoscopy (DGEN)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
20	Diploma in Infertility & Assisted Reproductive Technique (DIART)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
21	Diploma in Urology (DURO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
22	Diploma in Immunology (DIMM)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
23	Diploma in Intensive Care (DICU)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
24	Diploma in Neurology (DNEU)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
25	Diploma in Nephrology (DNEP)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
26	Diploma in Haemato Oncology (DHON)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
27	Diploma in Paediatric Orthopaedics (DPORTHO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
28	Diploma in Paediatric Intensive Care (DPICU)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
29	Diploma in Paediatric Neurology (DPNEU)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
30	Diploma in paediatric Cardiology (DPCARD)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
31	Diploma in Neonatology (DNEO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
32	Diploma in Paediatric Nephrology (DPNEP)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
33	Diploma in Learning Disability & Neuro Developmental Paediatrics (DLDNP)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
34	Diploma in Paediatric Gastroenterology, Hepatology & Nutrition(DPGHN)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
35	Diploma in Paediatric Urology (DPURO)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.
36	Diploma in Emergency Medicine (DEME)	This shall be recognised medical qualification when granted by College of Physicians and Surgeons, Mumbai on or after March 2012.

De-recognising the above courses, the Ministry has given approval for recognition to following Membership and Fellowship courses granted by College of Physicians and Surgeons, Mumbai namely: –

S.NO	Course Name	Recognition
1	Membership of College of Physicians and Surgeons, Mumbai (MCPS)	This qualification shall be a recognized medical qualification only when granted after the 30th April, 1944
2	Fellowship of the College of Physicians and Surgeons, Mumbai in Medicine (FCPS (Med.))	This qualification shall be a recognized medical qualification only when granted after the 30th April, 1954
3	Fellowship of the College of Physicians and Surgeons, Mumbai in Pathology (FCPS (Path.))	This qualification shall be a recognized medical qualification only when granted after the 30th April, 1954
4	Fellowship of the College of Physicians and Surgeons, Mumbai in Surgery (FCPS (Surg.))	This qualification shall be a recognized medical qualification only when granted after the 30th April, 1954
5	Fellowship of the College of Physicians and Surgeons, Mumbai in Dermatology (FCPS (Derm.))	This qualification shall be a recognized medical qualification only when granted after the 30th April, 1954
6	Fellowship of the College of Physicians and Surgeons, Mumbai in Midwifery and Gynaecology (FCPS (Mid. & Gyn.))	These qualifications shall be recognized medical qualifications under this schedule only when they are held by persons holding any other medical qualification specified in this Schedule.
7	Fellowship of the College of Physicians and Surgeons, in this Schedule. Mumbai in Ophthalmology (FCPS (Opth.))	These qualifications shall be recognized medical qualifications under this schedule only when they are held by persons holding any other medical qualification specified  in this Schedule.

The government has again clarified the following

(i) All the admissions should be through NEET-PG and centralized counselling and as per Government policy from time to time.

(ii) The CPS qualifications shall not be treated as a recognized medical qualification for the purpose of teaching.

Medical Dialogues team had earlier reported that vide notification in the Gazette the Ministry in the month of October 2017 had given recognition to the CPS courses

Read more at Medical Dialogues: U-Turn: Ministry of Health De-Recognizes PG diplomas offered by CPS, Mumbai https://medicaldialogues.in/u-turn-ministry-of-health-de-recognizes-pg-diplomas-offered-by-cps-mumbai/

Lets Revise Sepsis. An article by Dr KK Aggarwal, Recipient of Padma Shri.

Dr Bawa-Garba Case:Lets Revise Sepsis

Dr KK Aggarwal,  19 February 2018

The conviction of Dr Hadiza Bawa-Garba on the charges of manslaughter by gross negligence following the death of Jack Adcock, a 6-year-old boy with Down syndrome in 2011 has generated controversy. The successful appeal by the GMC to erase her name from the medical register has shaken the medical community not only in the UK, but outside UK also and angered many.

Missing the diagnosis of sepsis and thus delaying initiating antibiotic treatment was among the series of charges leveled against her.

Sepsis and septic shock are life-threatening conditions if not detected and managed in time. A high index of clinical suspicion along with a thorough clinical examination of the patient supported by appropriate lab tests is essential for the early diagnosis of sepsis.

Let’s revise some important aspects of sepsis, a potentially avoidable cause of death

• Sepsis is the consequence of a dysregulated inflammatory response to an infectious insult. 

• Sepsis exists on a continuum of severity ranging from infection (invasion of sterile tissue by organisms) and bacteremia (bacteria in the blood) to sepsis and septic shock, which can lead to multiple organ dysfunction syndrome (MODS) and death.

• Septic shock is defined as sepsis that has circulatory, cellular, and metabolic abnormalities that are associated with a greater risk of mortality than sepsis alone; these abnormalities can be clinically identified as patients who fulfill the criteria for sepsis who, despite adequate fluid resuscitation, require vasopressors to maintain a mean arterial pressure (MAP) ≥65 mmHg and have a lactate >18 mg/dL.

• Patients with suspected or documented sepsis typically present with hypotension, tachycardia, fever, and leukocytosis. As severity worsens, signs of shock (e.g., cool skin and cyanosis) and organ dysfunction develop (e.g., oliguria, acute kidney injury, altered mental status) 

• Poor prognostic factors: Inability to mount a fever, leukopenia, age >40 years, certain comorbidities (e.g., AIDS, hepatic failure, cirrhosis, cancer, alcohol dependence, immunosuppression), a non-urinary source of infection, a nosocomial source of infection, and inappropriate or late antibiotic coverage. Sepsis is a clinical syndrome characterized by systemic inflammation due to infection. 

• There is a continuum of severity ranging from sepsis to septic shock. Mortality has been estimated to be ≥10% and ≥40% when shock is present.

• First aid: Securing the airway (if indicated) and correcting hypoxemia, and establishing venous access for the early administration of fluids and antibiotics

• Supplemental oxygen should be supplied to all patients with sepsis and oxygenation should be monitored continuously with pulse oximetry. 

• Venous access should be established as soon as possible in patients with suspected sepsis. 

• An initial brief history and examination, as well as laboratory, microbiologic, and imaging studies are often obtained simultaneously while access is being established and the airway stabilized. 

o    TLC along with differential count, blood chemistries, liver function tests, and coagulation studies including D-dimer level.

o    An elevated serum lactate (eg, >2 mmol/L or greater than the laboratory upper limit of normal) may indicate the severity of sepsis.

o    Arterial blood gas (ABG) analysis – ABGs may reveal acidosis, hypoxemia, or hypercapnia.

o    Peripheral blood cultures (aerobic and anaerobic cultures from at least two different sites), urinalysis, and microbiologic cultures (eg, sputum, urine, intravascular catheter, wound or surgical site, body fluids) from readily accessible sites – For patients with a vascular catheter, blood should be obtained both from the catheter and from peripheral sites.

o    Imaging targeted at the suspected site of infection is warranted (eg, chest radiography, computed tomography of chest and/or abdomen).

o    Procalcitonin –has become increasingly popular. 

• The cornerstone of initial resuscitation is the rapid restoration of perfusion and the early administration of antibiotics.

• Tissue perfusion is predominantly achieved by the aggressive administration of intravenous fluids (IVF), usually crystalloids (balanced crystalloids or normal saline) given at 30 mL/kg (actual body weight) within the first three hours following presentation. Empiric antibiotic therapy is targeted at the suspected organism(s) and site(s) of infection and preferably administered within the first hour.

• Components of the protocols usually included the early administration of fluids and antibiotics (within 1 to 6 hours using the following targets to measure the response: central venous oxyhemoglobin saturation (ScvO2) ≥70%, central venous pressure (CVP) 8 to 12 mmHg, mean arterial pressure (MAP) ≥65 mmHg, and urine output ≥0.5 mL/kg/hour. 

• Intravenous (IV) fluids (first three hours): In patients with sepsis, intravascular hypovolemia is typical and may be severe, requiring rapid fluid resuscitation. There is no difference in mortality when mean infusion volumes of 2 to 3 liters were administered in the first three hours compared with larger volumes of three to five liters, which was considered standard therapy at the time. Fluid therapy should be administered in well-defined (e.g., 500 mL), rapidly infused boluses. 

• Empiric antibiotic therapy (first hour): Optimal doses of appropriate IV antibiotic therapy should be initiated within one hour of presentation, preferably after cultures have been obtained.

• Although the feasibility of a one hour target has not been assessed, the rationale for choosing it is based upon several observational studies that report poor outcomes with delayed (even beyond one hour), inadequately dosed, or inappropriate (i.e., treatment with antibiotics to which the pathogen was later shown to be resistant in vitro) antimicrobial therapy

• Broad spectrum is defined as therapeutic agent(s) with sufficient activity to cover a range of gram negative and positive organisms (eg, carbapenem, piperacillin-tazobactam). Many patients with septic shock should receive combination therapy with at least two antimicrobials from two different classes (ie, combination therapy) depending on the organisms that are considered likely pathogens and local antibiotic susceptibilities. Combination therapy is defined as multiple antibiotics given with the intent of covering a known or suspected pathogen with more than one agent.

• Among organisms isolated from patients with sepsis, the most common include Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Streptococcus pneumoniae, such that coverage of these organisms should be kept in mind when choosing an agent

• Clinicians should pay attention to maximizing the dose in patients with sepsis and septic shock using a full "high-end" loading dose 

• De-escalation and duration of antimicrobial agents should be assessed daily.

References

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2. N Engl J Med 2014;370:1683.
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6. N Engl J Med 2017.
7. Upodate.com