Blood glucose management in the intensive care unit : insulin infusion protocol

Stress hyperglycaemia is associated with poor clinical outcomes in critically ill patients. Factors contributing to hyperglycemia in critical illness include the release of stress hormones, the use of medications, the release of mediators in sepsis and trauma and insulin resistanc

Enteral Nutrition in Intensive Care: 'Tiger Tube'-For Small Bowel Feeding in Acute Pancreatitis. Case Report.

Nutritional support is vital in improving the clinical outcomes of the critically ill patients. Almost all published guidelines regarding nutritional support in the critically ill recommend the use of enteral nutrition over parenteral nutrition. In acute pancreatitis, trial of enteral feeding should be given into the small bowel. The success rate of small bowel feeding tube is highest if inserted endoscopically. In this case report, a simple bedside procedure which did not require endoscopic feeding tube placement offered a good alternative. Self advancing small bowel feeding tube, Tiger tube was inserted successfully to provide nutritional support in moderately severe acute pancreatitis

Acute airway obstruction due to Ascaris Lumbricoides in a ventilated child

Ascaris lumbricoides or roundworm is a nematode causing infestation in about 1.3 billion people worldwide. We report a case of a 7-year-old patient who had head injury. He was admitted to the intensive care unit for mechanical ventilation after craniotomy and evacuation of extradural haemorrhage at the left temporoparietal area. While weaning off mechanical ventilation two days after admission, he developed an acute airway obstruction. Flexible bronchoscopy revealed a tube like foreign body obstructing the right and left bronchus. Emergency rigid bronchoscopy under general anaesthesia extracted an eight-centimetre long Ascaris lumbricoides. The patient’s ventilation and oxygenation improved drastically and he was discharged home 3 weeks later

Refeeding syndrome in a Malaysian intensive care unit: an assessment of incidence, risk factors and outcome

Objective: Refeeding hypophosphataemia (RH) is characterised by acute electrolyte derangement following the start of nutrition. Complications associated with this syndrome include heart failure, respiratory failure, paraesthesia, seizure and death. We aim to assess its incidence, risk factors, and outcome in our local intensive care unit (ICU). Methods: This is a preliminary analysis prospective observational study at the ICU of Hospital Tengku Ampuan Afzan Kuantan. The study was registered under the National Medical Research Register (NMRR-14-803-19813) and has received ethical approval. Inclusion criteria includes adult admission longer than 48 hours who were started on enteral feeding in the ICU. Chronic renal failure patients and those receiving dialysis were excluded. RH was considered if plasma phosphate was less than 0.65 mmol/l within 7 days of ICU admission. Results: A total of 108 patients were recruited into the study. Of this, 51 (47.2%) had RH. Patients with RH had higher SOFA score compared to those without RH (7.1±3.0 vs 5.7±3.4, p=0.02). There were no differences in the APACHE II score (16±6 vs 15±6, p=0.30), and in the NUTRIC score (2.9±1.7 versus 2.7±1.7, p=0.63) between patients with and without RH. Patients with RH had lower albumin concentration compared to those without RH (23 vs 25, p=0.04). There were lower trend of magnesium, calcium and potassium concentration, however these were not statistically significant. All four patients with hypomagnesaemia (less than 0.5 mmol/l) had RH (p=0.04). There were no differences in mortality, length of hospital or ICU stay and duration of mechanical ventilation. Conclusion: Refeeding hypophosphataemia is common, occurring in almost half of ICU admission. Patients with RH had higher organ failure score, and lower albumin level. There were no differences in the NUTRIC score and in short-term outcomes. Further studies could evaluate the association between RH and long-term outcome

Procalcitonin and Interleukin-6 for predicting culturenegative and culture positive bacterial sepsis in critically ill patients with systemic inflammatory response syndrome

Introduction: Differentiation between culture-negative bacterial sepsis (BS), culturepositive BS and non-infectious systemic inflammatory response syndrome (SIRS) among critically ill patients remains a diagnostic challenge to the intensive care unit (ICU) physicians. This study aimed to evaluate the role of procalcitonin (PCT) and interleukin-6 (IL-6) in predicting non-infectious SIRS, culture-negative BS and culture-positive BS in the ICU. Methods: This prospective observational study was conducted in a tertiary ICU in Pahang. The patients were divided into sepsis and non-infectious SIRS based on clinical assessment with or without positive cultures. Patients with positive cultures were further divided into bacteraemia and positive other culture. The PCT and IL-6 were measured daily over the first 3 days. Results: Two hundred and thirty nine consecutive patients diagnosed with SIRS were recruited, of whom 164 (69%) had sepsis. Among sepsis patients, there were 62 (37.8%) culture positive and 102 (62.2%) culture negative. Of these, 27 (16.5%) develop bacteraemia. The most common site of infection was respiratory (34.4%). Post-LSD analyses showed significant difference in the PCT between culture negative sepsis and SIRS (p=0.01); and positive other culture and SIRS (p=0.04).  On the other hand IL-6 cannot differentiate between SIRS and negative culture sepsis (p=0.06). Both PCT and IL-6 predicted bacteraemia with an AUC of 0.70 (0.57 to 0.82) and 0.68 (0.53 to 0.70). IL-6 is independently associated with bacteraemia and other culture after adjusting for age, sex, hypertension, SAPS II score and day 1 PCT. Conclusions: Procalcitonin but not Interleukin-6 is able to differentiate SIRS from culture-negative BS. However, IL-6 is independently associated with bacteraemia and other culture

Validating a Lower Urine Output Criteria in Predicting Death in Critically Ill Patients

Introduction: Urine output provides a rapid estimate for kidney function, and its use has been incorporated in the diagnosis of acute kidney injury. However, not many studies had validated its use compared to the plasma creatinine. It has been showed that the ideal urine output threshold for prediction of death or the need for dialysis was 0.3 ml/kg/h. We aim to assess this threshold in our local ICU population. Methods: This was a secondary analysis of an observational study done in critically ill patients. Hourly urine output data was collected, and a moving average of 6-hourly urine output was calculated over the first 48 hours of ICU admission. AKIuo was defined if urine output ≤ 0.5 ml/kg/h, and UO0.3 was defined as urine output ≤ 0.3 ml/kg/h. Results: 143 patients were recruited into the study, of these, 87 (61%) had AKIuo, and 52 (36%) had UO0.3. The AUC of AKIuo in predicting death was 0.62 (0.51 to 0.72), and UO0.3 was 0.66 (0.55 to 0.77). There was lower survival in patients with AKIuo and UO0.3 compared to those without (p=0.01, and 0.001, respectively). However, only UO0.3 but not AKIuo independently predicted death (HR 2.44 (1.15 to 5.18). Conclusions: A threshold of 6 hourly urine output of 0.3 ml/kg/h but not 0.5 ml/kg/h independently predictive of death. This support previous finding of a lower threshold of urine output criteria for optimal prediction

The Theory of Fuzzy Logic and its application to Real Estate Valuation

Fuzzy logic is based on the central idea that in fuzzy sets each element in the set can assume a value from 0 to 1, not just 0 or 1, as in classic set theory. Thus, qualitative characteristics and numerically scaled measures can exhibit gradations in the extent to which they belong to the relevant sets for evaluation. This degree of membership of each element is a measure of the element’s "belonging" to the set, and thus of the precision with which it explains the phenomenon being evaluated. Fuzzy sets can be combined to produce meaningful conclusions, and inferences can be made, given a specified fuzzy input function. The article demonstrates the application of fuzzy logic to an income-producing property, with a resulting fuzzy set output