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Performing a point-of-care ultrasound (POCUS) scan in critical care, along with the incorporation of the findings into a clinical pathway, has now become the standard of care. The Indian Society of Critical Care Medicine (ISCCM) has established an ultrasound network and released the desirable competencies for intensive care unit (ICU) clinicians regarding the same. This survey was performed to study the practice patterns and barriers to utilizing POCUS among various specialists across Indian ICUs. An online survey-based, cross-sectional, multicenter, observational study was conducted over a period of 3 months with a questionnaire based on the utility, skills, training, and comfort in performing POCUS in Indian ICUs. A total of 864 responses were received and analyzed. A total of 67.4% among them were specialists in critical care medicine, and 67.2% had received some form of training in POCUS. Most clinicians reported using POCUS for lung assessments, volume status evaluation, and focused cardiac assessments. Key barriers were inadequate training, limited machines, lack of supervision, time constraints, and medicolegal issues, though 32.4% reported no major obstacles. The majority of participants agreed that POCUS enables more efficient and safer care for critically ill patients. 624/864 respondents strongly agreed that POCUS training is essential for intensivists. Point-of-care ultrasound is being increasingly adopted across various specialties in critical care settings. This survey highlights the practice pattern of POCUS across India and possible limitations in expanding the role of POCUS for the management of critically ill. CTRI/2022/09/045417. Pal D, Govil D, Pachisia AV, Soni KD, Gupta S, Kothekar AT, et al. Practice Pattern of Critical Care UltraSonography in India (POCUS India): A Multicenter Cross-sectional Survey. Indian J Crit Care Med 2026;30(5):398-407.
The Procedure Specific Postoperative Pain Management (PROSPECT) collaboration develops evidence-based recommendations integrating analgesic efficacy, safety and functional recovery. Since publication of the 2021 PROSPECT guidelines for total hip arthroplasty, new evidence, particularly on motor-sparing regional techniques, has emerged. This systematic review updates the 2021 recommendations for postoperative pain management after elective primary total hip arthroplasty. Databases were searched systematically for randomised controlled trials and systematic reviews published between January 2020 and June 2024 evaluating peri-operative analgesic or surgical interventions for total hip arthroplasty. Studies involving non-randomised designs or lacking validated pain outcomes were not included. Evidence was synthesised according to PROSPECT methodology, focusing on pain within 24 h; opioid consumption; functional recovery; and adverse effects. Recommendations were graded by expert consensus. A total of 103 studies were included. Core recommendations remain unchanged: scheduled paracetamol and non-steroidal anti-inflammatory drugs, combined with a single intravenous dose of dexamethasone (≤ 10 mg). Low-dose intrathecal morphine (0.1 mg) may be considered with spinal anaesthesia in hospitalised patients. Among regional techniques, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block provided the most consistent analgesia. Quadratus lumborum and lumbar erector spinae plane blocks showed inconsistent efficacy and increased risk of motor weakness and are not recommended. Single-shot local infiltration analgesia remains an alternative when regional techniques are unavailable. In addition to previous recommendations, supra-inguinal fascia iliaca compartment block and pre-operative pericapsular nerve group block are recommended as preferred regional techniques for total hip arthroplasty, with single-shot local infiltration analgesia as an alternative when regional anaesthesia is not feasible. A group of researchers looked at all the best available studies about pain relief after hip replacement surgery. They reviewed research published since 2020 and combined the findings to update earlier recommendations on how to manage pain after surgery. Hip replacement surgery can be painful, and good pain relief helps people recover more quickly and comfortably. New research has become available in recent years, so the researchers wanted to find out which treatments work best and update advice for doctors and patients. The researchers found that regular pain medicines, such as paracetamol and anti‐inflammatory drugs, should still be used as the main treatment after hip replacement surgery. A steroid medicine called dexamethasone may also help reduce pain. Some types of nerve blocks around the hip were found to work well and are recommended when possible. However, other nerve block techniques did not show clear benefits and are not routinely recommended. Overall, the updated recommendations aim to provide safe and effective pain relief to help patients recover after hip replacement surgery.
Critical care medicine operates in an environment of profound uncertainty, where clinicians must make high-stakes decisions based on incomplete, evolving, and often conflicting information. Despite this, most critical care research is frequentist-based, relying on static thresholds, dichotomous interpretations of evidence, and delayed incorporation of new data. This paradigm may not fully align with the dynamic and probabilistic nature of critical illness. Bayesian approaches offer an alternative framework that explicitly incorporates prior knowledge, continuously updates probabilities as new data emerge, and supports real-time, individualized decision-making. Rather than asking whether an intervention "works" in a binary sense, Bayesian methods estimate the probability of benefit or harm in a given clinical context, thereby aligning more closely with bedside reasoning. Importantly, such approaches are no longer theoretical. Adaptive platform trials have demonstrated the feasibility of Bayesian methodologies at scale, enabling continuous learning, dynamic treatment allocation, and simultaneous evaluation of multiple interventions. In this viewpoint, we explore how Bayesian decision-making could extend beyond research into routine intensive care practice. We discuss its potential to enhance clinical judgment, personalize therapy, and integrate heterogeneous data streams into coherent probabilistic estimates. The question is no longer whether Bayesian methods can be implemented, but how quickly and effectively they can be embedded into everyday critical care practice.
BackgroundAdvance directives (ADs) document the patient's preferences regarding future medical care and are used to ensure goal-concordant care and patient autonomy when the patient becomes incapacitated. In a clinical setting, goals of care (GOC) discussions are a tool that helps health care providers (HCPs) provide goal-concordant care. A lack of documentation of the patient's wishes, either as AD or following GOC discussions, can, especially in emergency or critical situations, lead to moral distress among HCPs, a psychological disequilibrium that stems from the perceived inability to act in the best interests of the patient.ObjectivesThis study aimed to (1) assess attitudes toward GOC discussions among patients and HCPs in general wards at Vienna General Hospital, (2) identify barriers and facilitators for their implementation, and (3) measure and compare moral distress between HCPs.MethodsA cross-sectional survey was conducted between October 2022 and June 2023 across six wards (cardiology, pulmonology, infectious diseases, maxillofacial surgery, palliative care, and chronic haemodialysis). Paper-based questionnaires were administered to patients (n = 47) and HCPs (n = 75). Moral distress among HCPs was assessed using a culturally adapted German translation of the Measure of Moral Distress - Health Care Professionals (MMD-HP).Ethical considerationsThe study was approved by the ethics committee and the data protection commission of the Medical University of Vienna. Informed consent was obtained from all participants. The questionnaires contained no identifying information. Participation was voluntary and not participating carried no disadvantages.ResultsMost patients (70.5%) considered GOC discussions appropriate during hospitalisation, 71.4% considered them relieving, and 79.1% considered them helpful. Only 10.9% had ever been asked about ADs during a hospital stay. Among HCPs, the majority considered GOC discussions suitable for patients with multimorbidity (80.0%) and life-shortening conditions (86.7%) as well as those with a simple medical condition (54.7%). However, the majority (51.4%) of HCPs practice GOC discussions for less than 10% of their patients. The lack of standard operating procedures (SOPs), personnel, time, translators, and material were reported as the most relevant barriers. The mean MMD-HP total score was 105.0. Nurses scored significantly higher than physicians (125.7 vs 86.9, p = 0.020).ConclusionsBoth patients and HCPs expressed strong support for GOC discussions, yet the implementation is hindered by resource limitations and the lack of standardised protocols. At the same time, nurses experience high levels of moral distress. There seems to be a need for organisational and policy measures to facilitate structured GOC discussions and goal-concordant care.
Sleep disorders profoundly impair patients' daily quality of life and present substantial challenges to clinical management. Accumulating evidence has shown that propofol improves sleep architecture and quality in clinical practice, yet its mechanism in modulating pain linked to sleep disorders remains elusive. Given that chronic sleep disruption is often accompanied by impaired pain thresholds and imbalances between excitatory and inhibitory neurotransmitters, this study aimed to determine whether propofol alleviates sleep-deprivation-induced pain threshold reduction by modulating this neurotransmitter balance. A modified multi-platform water maze was used to establish a sleep-deprived mouse model simulating sleep disruption. Following tail vein administration of varying propofol doses, behavioral assessments were conducted to evaluate its effects on sleep states and pain thresholds. Concurrently, electroencephalogram (EEG) and electromyogram (EMG) recordings captured sleep rhythm alterations. To further investigate neurochemical mechanisms, 9.4 T MRI and amino acid metabolism analysis were employed to obtain magnetic resonance spectroscopy (MRS) data. Glutamate (Glu) and γ-aminobutyric acid (GABA) levels in the thalamus and cortex were measured to assess dynamic changes in the excitatory/inhibitory neurotransmitter balance. Our results demonstrated that sleep deprivation significantly reduced the pain threshold in mice, which was accompanied by an imbalance in the thalamocortical Glu/GABA ratio. Propofol intervention markedly restored this neurotransmitter imbalance - the Glu/GABA metabolic ratio returned to a relatively stable level, and the reduced pain threshold was significantly improved. Concurrent EEG and EMG recordings revealed that propofol optimized sleep architecture and partially reversed sleep rhythm disturbances caused by sleep deprivation. In summary, propofol effectively alleviates sleep-deprivation-induced pain reduction in pain threshold. This analgesic effect is associated with the restoration of the dynamic equilibrium of excitatory/inhibitory neurotransmitters (Glu/GABA) in the thalamocortical circuit. Our findings provide novel experimental and neurochemical evidence supporting the potential application of propofol in sleep disorders and associated pain management, thereby offering a valuable reference for future clinical translational research.
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The postanesthesia care unit is a critical phase of recovery, yet routine assessment often focuses on discharge readiness rather than the child's recovery experience. This study reviewed measures used in pediatric postanesthesia care unit pathways to assess discharge readiness and early recovery quality and synthesized how they capture domains that matter to children, families, and clinicians. This is a structured literature review with narrative synthesis and identified eight tools used in children: Steward score, Modified Aldrete Score, physiologic criteria-based score, White and Song fast-track score, Criteria for Fast-Tracking Children, Pediatric Post-Anesthetic Discharge Scoring System, Pediatric Readiness for Discharge Instrument, and Discerning Post Anesthesia Readiness for Transition. These tools varied by intended phase and destination, with consistent coverage of consciousness, oxygenation, and hemodynamics but variable assessment of the airway, pain, nausea and vomiting, bleeding, and function. A postanesthesia care unit-specific pediatric quality-of-recovery measure remains a key research and quality improvement gap.
Colonization with difficult-to-treat-resistant Gram-negative bacteria (DTR-GNB) increases the risk of subsequent infections with limited treatment options. This study aimed to assess the burden of DTR-GNB colonization in ICU patients, explore its association with clinical outcomes, and examine genomic similarities. This secondary analysis included patients enrolled within 24 h of ICU admission between July 2023 and January 2024. Rectal swabs were collected at enrollment, on days 3, 7, and weekly during ICU stay to detect colonization. Bacterial isolates grown on selective chromogenic agar media were identified and tested for antimicrobial susceptibility using matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and automated broth microdilution, respectively. Blood, urine, and/or tracheal aspirate cultures were performed if clinically suspected sepsis. Whole-genome sequencing (WGS) was performed on paired colonization and infection isolates, and genomic relatedness was assessed using FastANI, core-genome single-nucleotide polymorphism (SNP) analysis, and phylogenetic reconstruction. Among 373 patients, 181 (48.5%) were colonized with DTR-GNB; 76 (20.4%) at enrollment, and 105 (53.0%) acquired during hospital stay. Among 52 (13.9%) patients evaluated for suspected infection, 30 (57.7%) had positive cultures, predominantly Acinetobacter baumannii (n = 15) and Klebsiella pneumoniae (n = 11) of DTR-phenotypes. Compared to non-colonized patients, patients colonized with DTR-GNB had higher risks of infections (risk ratio [RR]: 2.18, 95% CI: 1.27-3.76) and longer ICU stays (median 7 vs 2 days, P < 0.001). DTR-GNB-infected patients had a higher risk of death (RR: 1.57, 95% CI: 1.34-1.84) compared to patients without DTR-GNB infection. WGS revealed that 13 of 14 paired colonization-infection isolates were conspecific, with three pairs being highly clonal; whereas the remaining pairs showed greater genomic divergence, consistent with the SNP and phylogenetic analyses. While common, more than half acquired DTR-GNB colonization from the ICU. Its association with subsequent infection and prolonged ICU stays underscores the need for enhanced infection prevention and control measures to mitigate nosocomial transmission and improve patient outcomes.IMPORTANCEThis study underscores the growing threat posed by difficult-to-treat resistant Gram-negative bacteria (DTR-GNB) in intensive care units. Nearly half of critically ill patients were colonized, with a considerable proportion acquiring these multidrug-resistant organisms during their ICU stay. Colonization with these pathogens substantially increased the risk of subsequent infections, even by the same colonizing strain, prolonged ICU stays, and likely worsened clinical outcomes due to the unavailability of susceptible antibiotics. Alarmingly, more than 90% of patients infected with DTR-GNB expired in the hospital. These findings highlight the urgent need for robust infection prevention and control strategies to curb nosocomial transmission and mitigate the impact of DTR-GNB on vulnerable patient populations. Addressing this emerging resistance phenotype is critical to improving patient safety and reducing the burden on healthcare systems.
Spinal cord stimulation is routinely used to treat medically intractable pain. Different stimulation designs exist for pain suppression. Among these, both high-frequency stimulation at 10 kHz and burst stimulation are paresthesia-free, and it has been postulated, on the basis of theoretical and clinical grounds, that they may be fundamentally the same, ie, that both modulate the medial "suffering" pathway rather thantonic stimulation; yet no proof exists for this proposal. Clinical and electroencephalographic (EEG) data from ten patients undergoing both burst with passive recharge and 10 kHz spinal cord stimulation for ten days are analyzed to examine the commonalities and differences between burst and 10 kHz stimulation. A source localized (standardized low-resolution brain electromagnetic tomography) EEG subtraction and conjunction analysis is performed in each condition. Burst and 10 kHz significantly reduced leg pain to a similar extent. For back pain, burst showed a substantial reduction from baseline, whereas 10 kHz did not; however, the direct comparison between burst and 10 kHz was not significant. Brain differences were observed in alpha-band activity within medial cingulate and operculo-insular regions during burst relative to 10 kHz, whereas both paradigms shared beta activity with a peak in the pregenual anterior cingulate region. Given the 19-channel montage, these anatomic assignments should be interpreted cautiously. Burst and 10 kHz stimulation share beta activation in the pregenual anterior cingulate cortex (pgACC). The common pgACC activation correlates with the degree of pain suppression in both the back and the legs. The dorsal anterior cingulate cortex deactivation correlates with back pain reduction in burst. For 10 kHz, there is no significant correlation. These data suggest that burst and 10 kHz stimulation both modulate the descending pain-inhibitory system (through pgACC), thereby decreasing both back and leg pain. Burst also modulates the dorsal anterior cingulate cortex, subgenual anterior cingulate cortex, and insula, which correlate with changes in back pain.
Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery. The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence. Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals. Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.
Alterations of acid-base balance induced by intravenous fluids are primarily related to changes in plasma strong ion difference (SIDPL) and nonvolatile weak acids. Previous studies suggest that the relationship between the SID of infused fluids (SIDINF) and pre-infusion plasma bicarbonate (HCO3 -) may act as an integrative factor influencing acid-base changes during fluid replacement. However, the contribution of unmeasured anions and renal electrolyte handling remains incompletely characterized. We conducted a prospective observational study in postoperative critically ill adults receiving intravenous fluids early after admission to intensive care unit (ICU). Fluid composition and volume were recorded. Acid-base variables, plasma and urinary electrolytes were assessed at ICU admission and study end (postoperative-day one). The average SIDINF and SIDINF-HCO3 - difference were calculated. Patients were grouped by crystalloid type and SIDINF-HCO3 - tertiles. Associations with changes in SIDPL, standard base excess (SBE), strong ion gap (SIG), and urinary anion gap (uAG) were analyzed. Fifty-seven consecutive patients were included. Patients received 3,152 ± 1,027 mL of fluids, with a slightly positive fluid balance (+802 ± 1,212 mL) over 19 [18-20] hours. SIDPL (38.7 ± 2.4 to 39.8 ± 2.7 mEq/L) and SBE (-1.5 ± 2.4 to 0.9 ± 2.9 mEq/L) increased (p < 0.001 for both), whereas SIG decreased (5.0 ± 2.8 to 3.9 ± 2.5 mEq/L; p < 0.001), indicating reduced unmeasured anions. Changes in SIDPL and SBE increased across crystalloid groups and SIDINF-HCO3 - tertiles, with minimal SBE variation when SIDINF-HCO3 - approximated zero. SIG changes were similar across groups. Urinary electrolyte excretion showed no quantitative association with SIDPL or SBE changes; however, urinary Cl- decreased with increasing SIDINF-HCO3 -, consistent with renal Cl- modulation. In postoperative critically ill patients, SIDINF-HCO₃- appears to influence fluid-induced acid-base changes, particularly during fluid replacement. Changes in unmeasured anions also contribute to SBE variations. In contrast, renal effects appear temporally limited and do not quantitatively influence plasma acid-base status over short time frames.
Hypoxaemia occurs in approximately 30% of children undergoing anaesthesia for flexible bronchoscopy. Nasal high-flow oxygen (NHF) can prolong safe apnoea time and be used in children with abnormal airways. During flexible bronchoscopy, there is limited evidence that NHF may confer advantages over the current standard practice in avoiding hypoxaemia. This study aimed to evaluate the feasibility of recruitment to a protocol investigating NHF during anaesthesia for flexible bronchoscopy, with the objective of reducing rescue oxygenation and hypoxaemia. The BUFFALO study was a bi-centre, unmasked, randomised, controlled, parallel-group pilot trial comparing NHF techniques with standard practice during anaesthesia. Children aged >37 weeks gestational age to 16 years presenting for elective bronchoscopy were randomised to NHF or standard-care oxygen post-induction of anaesthesia. Outcomes included the feasibility of recruitment, hypoxaemic events, rescue oxygenations, adherence to trial procedures, acceptability of the intervention, and completion rates of data collection methods. Of the 707 children screened, 89 children were eligible, 81 children were recruited, 43 to the NHF, and 38 to the standard care group. The feasibility outcomes were: proportion of eligible children recruited 91% (95%CI [85,97]), protocol adherence 93% (95%CI [87,98]), and completion rate 100%. The technique of using NHF during flexible bronchoscopies in children and the protocol for this trial were feasible in the two participating centres. However, respiratory physicians' hesitancy to use this technique in high-risk children and concerns about the potential for translocation of upper airway infectious material into the lower airways reduced the number of eligible patients.
To compare clinical outcomes between urinary and non-urinary tract sepsis in nonagenarians and centenarians admitted to intensive care units (ICUs). Retrospective propensity score-matched multicentre cohort study. Adult ICUs participating in the Australian and New Zealand Intensive Care Society Adult Patient Database across Australia and New Zealand (2010-2023). We included all ICU admissions for sepsis in patients aged 90 years or older, classified as urinary or non-urinary tract sepsis using Acute Physiology and Chronic Health Evaluation III-J diagnostic codes. After 1:1 nearest neighbour propensity score matching, 1130 patients (565 per group) were included. The primary outcome was all-cause mortality within 180 days and beyond 180 days. Secondary outcomes included ICU mortality, hospital mortality, ICU length of stay and hospital length of stay. Of 1669 patients, 573 had urinary tract sepsis and 1096 had non-urinary tract sepsis. After matching, 1130 patients were included (565 per group). In the matched cohort, non-urinary tract sepsis was associated with higher mortality within 180 days than urinary tract sepsis (HR 1.67, 95% CI 1.33 to 2.09, p<0.001), whereas mortality beyond 180 days did not differ (HR 1.03, 95% CI 0.80 to 1.34, p=0.816). ICU and hospital length of stay were similar between groups. Among nonagenarian and centenarian ICU patients with sepsis, infection source was an important determinant of early but not late mortality, with non-urinary tract sepsis conferring a higher risk than urinary tract sepsis. Incorporating infection source and simple physiological markers alongside illness severity scores may improve prognostication and support shared decision-making in this very old population.
High-flow nasal cannula (HFNC) in bronchiolitis is widely used beyond guideline recommendations. This study developed targeted, theory-informed implementation strategies to improve appropriate HFNC use in regional and rural emergency departments (EDs), to be evaluated in a cluster randomised controlled trial (cRCT). A 3-phase process mapping and implementation science approach was embedded in a clinician co-design study involving 12 senior clinicians (5 nurses, 7 doctors) from Australian regional and rural EDs. International and Australian literature informed discussions. Barriers were coded using the Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR 2.0) with strategy co-design guided by CFIR-ERIC and TDF-BCT linkages. Five HFNC decision nodes were identified: assessment of hypoxaemia, low-flow oxygen trial and reassessment, escalation to HFNC, weaning and cessation, and escalation of care. Behavioural factors included fear of deterioration, limited confidence in respiratory assessment, and norms favouring early escalation. Contextual factors included limited paediatric expertise, staff turnover, and unclear de-escalation. Findings informed strategies including targeted education, clinical pathways and audit and feedback. Process mapping identified behavioural and contextual drivers of inappropriate HFNC use informing implementation strategies and offering a practical, scalable approach to translating guidelines into routine ED practice. This study identifies behavioural and contextual drivers of inappropriate high-flow nasal cannula use in infants with bronchiolitis across regional and rural emergency departments. Using structured process mapping and clinician co-design, we mapped decision-making at key clinical nodes and developed targeted, theory-informed implementation strategies to address identified barriers. Findings directly informed educational content and implementation strategies being evaluated in a cluster randomised controlled trial across 30 regional and rural hospitals. This work provides a practical, scalable framework for translating guidelines into routine emergency department practice, with relevance beyond bronchiolitis to other high-variation clinical behaviours in acute care.
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Sugammadex is highly effective in reversing neuromuscular block, but costly and not without known complications. Subjectively determined empiric dosing of sugammadex for routine antagonism of neuromuscular block risks over- or under-dosing patients and leads to increases in drug acquisition costs, especially in markets where generics remain unavailable. We hypothesized that our recently implemented sugammadex aliquoting policy and its administration guided by quantitative neuromuscular monitoring would lower the cost of empirically dosed sugammadex antagonism. This retrospective analysis of 524 patients evaluated the pharmacoeconomic impact of sugammadex aliquoting and administration guided by quantitative neuromuscular monitoring versus subjectively determined routine antagonism of neuromuscular block in adults having elective surgical procedures. This single-center retrospective deidentified chart review included adult patients having elective surgical procedures requiring general anesthesia. Cost of sugammadex ($129.05/200-mg vial) antagonism was based on the assumed routine administration of 1 vial. When using sugammadex aliquots (50 mg/0.5 mL), the dose saved was calculated as 200 mg minus total aliquots used. Gross cost savings per patient were determined by subtracting cost (labor, supplies, drug acquisition) of individual aliquots from actual sugammadex vials acquisition cost. Using neostigmine ($1.99/10 mg vial) and glycopyrrolate ($1.74/0.4 mg vial), the total per-case cost was determined by the number of full vials administered. Actual net cost savings/case included sensor cost ($20.00) and hardware cost ($1995/monitor amortized over 7 years) from gross savings per surgical case. In patients receiving sugammadex aliquots (n = 258), the mean gross cost was $51.50 (mean gross savings, $77.55/case vs. full-vial). Neostigmine/glycopyrrolate (n = 111) mean gross cost, $4.39/case. Patients managed without pharmacological reversal (n = 63) incurred no drug costs (savings of 200-mg sugammadex vial, $129.05). For all patients, mean gross (drugs only) and net (including monitoring) costs per case were markedly lower with aliquoting ($51.50 and $71.66, respectively) compared with full-vial use ($129.05 and $149.21, respectively). Aliquoting yielded total hospital net savings (including quantitative monitoring) of $20,008. Aliquoting and dosing sugammadex guided by quantitative neuromuscular monitoring in this single center reduces annual drug acquisition costs and produces consistent savings across dose ranges.
Headache disorders are a leading cause of disability worldwide, yet service delivery in low- and middle-income countries (LMICs) like Egypt remains understudied. This study aimed to assess the national landscape of headache care in Egypt, focusing on provider training, treatment access, medication availability, and systemic disparities. This cross-sectional study is part of a larger multinational initiative conducted under the auspices of the International Headache Society (IHS). The study included 321 Egyptian neurologists. The data collection process was carried out through both electronic surveys and in-person interviews. The surveys included questions covering the following items: profile of headache patients, characteristics of healthcare services available for headache patients, headache medication choices and affordability, and perceived barriers to proper headache management. Based on the neurologists' perspective, the primary headaches accounted for 85% (65-90%) of all headache cases, whereas secondary headaches accounted for 10% (5-20%) of headache cases. About 91.9% of the neurologists reported that anxiety was the most common comorbidity with headache, followed by depression (81.9%). Approximately 80.1% (n = 257) of patients had to pay to access medicine, and the estimated percentage of patients who could afford medication was 60 (40-70). The average number of headache patients assessed by each specialist per week was estimated to be 25 (10-50) patients. About 89.7% (n = 288) of the participants reported receiving formal training on the diagnosis and treatment of migraine. Seeking medical advice from non-specialized physicians was reported by 82.9% of the included participants to be one of the commonest causes for the delayed diagnosis of headache. Most participants (76.6%) reported that financial constraints may be a contributing factor to non-compliance with medications in patients with headaches. This study identifies urgent gaps in the equity, affordability, and structure of headache care in Egypt. Policy action is needed to implement structured headache services, expand provider training, and improve access to essential and newly developed medications.