Development and validation of creatinine-based estimates of the Glo- Merular Filtration rate equation from Chromium Edta Imaging in the multi-racial Malaysian population

Background Glomerular filtration rate (GFR) is a reliable parameter for assessing kidney function. It is estimated from equations such as Cockcroft–Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease- Epidemiology Collaboration (CKD-EPI). However, these equations were derived using Western population demo- graphic data and had different performances when applied to other populations. Objectives. We developed a new equation (NE) based on the 51Cr EDTA measured GFR that can be used explicitly in the Malaysian multiracial population. Methods This was a cross-sectional study using the Electronic Medical Record (EMR) of pa- tients who underwent 51Cr-EDTA imaging at the Nuclear Medicine Centre, University Malaya Medical Centre (UMMC), from 2013 to 2021. This study had obtained approval from the Medical Research Ethics Committee, UMMC. Results Total data of 209 patients were recruited in this study. 105 were randomised in the development cohort, while 104 were in the validation cohort. A NE was developed based on data in the development cohort and then tested its performance in the validation cohort. The result showed that CKD-EPI had the highest correlation to 51Cr EDTA imaging measured GFR (r-value 0.82), followed by the NE (r-value 0.76). CG had the lowest bias (mean bias of 2.49), followed by the NE (mean bias of 3.52). CKD-EPI had the highest precision in estimating GFR (SD of 22.04ml/min), followed by the NE (SD of 25.05ml/min). CKD-EPI also had the highest accuracy (85.58% in P30 and 100% in P50, followed by MDRD (81.73% in P30 and 96.15% in P50). Conclusion The NE was less accurate than CKD-EPI and MDRD equation but generally has a rel- atively low bias of 3.52 ml/min. The limitation of the small sample size may limit the accuracy of the NE. Future studies with a larger sample size are needed to generate a more robust equation

Intractable intraoperative brain herniation secondary to tension pneumocephalus: a rare life-threatening complication during drainage of subdural empyema

Tension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage. Resumo: O pneumoencéfalo hipertensivo é raro, mas foi bem documentado após trauma e procedimentos neurocirúrgicos. Trata-se de uma emergência cirúrgica porque pode levar à deterioração neurológica, herniação do tronco cerebral e morte. Ao contrário de casos anteriores nos quais o pneumoencéfalo hipertensivo se desenvolveu no pós-operatório, descrevemos um caso de pneumoencéfalo hipertensivo desenvolvido no período intraoperatório levando a uma herniação cerebral súbita, maciça e aberta para fora do local da craniotomia. Os possíveis fatores causais são destacados. É imperativo identificar rapidamente as possíveis causas da herniação cerebral aguda no intraoperatório, incluindo o pneumoencéfalo hipertensivo, e instituir medidas apropriadas para minimizar os danos neurológicos. Keywords: Intraoperative brain herniation, Tension pneumocephalus, Hydrogen peroxide, Brain amputation, Palavras-chave: Herniação cerebral no intraoperatório, Pneumoencéfalo hipertensivo, Peróxido de hidrogênio, Amputação cerebra

Intractable intraoperative brain herniation secondary to tension pneumocephalus: a rare life-threatening complication during drainage of subdural empyema

Abstract Tension pneumocephalus is rare but has been well documented following trauma and neurosurgical procedures. It is a surgical emergency as it can lead to neurological deterioration, brainstem herniation and death. Unlike previous cases where tension pneumocephalus developed postoperatively, we describe a case of intraoperative tension pneumocephalus leading to sudden, massive open brain herniation out of the craniotomy site. The possible causative factors are outlined. It is imperative to rapidly identify possible causes of acute intraoperative brain herniation, including tension pneumocephalus, and institute appropriate measures to minimize neurological damage

Anesthesia in anti-N-methyl-d-aspartate receptor encephalitis – is general anesthesia a requisite? A case report

Anti-N-methyl-d-aspartate receptor encephalitis is a recently described neurological disorder and an increasingly recognized cause of psychosis, movement disorders and autonomic dysfunction. We report 20-year-old Chinese female who presented with generalized tonic–clonic seizures, recent memory loss, visual hallucinations and abnormal behavior. Anti-N-methyl-d-aspartate receptor encephalitis was diagnosed and a computed tomography scan of abdomen reviewed a left adnexal tumor. We describe the first such case report of a patient with anti-N-methyl-d-aspartate receptor encephalitis who was given a bilateral transversus abdominis plane block as the sole anesthetic for removal of ovarian tumor. We also discuss the anesthetic issues associated with anti-N-methyl-d-aspartate receptor encephalitis. As discovery of tumor and its removal is the focus of initial treatment in this group of patients, anesthetists will encounter more such cases in the near future. Resumo: A encefalite antirreceptor de N-metil-d-aspartato (NMDA) é um distúrbio neurológico recentemente descrito e uma causa cada vez mais reconhecida de psicose, distúrbios do movimento e disfunção autonômica. Relatamos o caso de uma paciente de origem Chinesa, 20 anos de idade, que se apresentou com crises tônico-clônicas generalizadas, perda de memória recente, alucinações visuais e comportamento anormal. Encefalite antirreceptor de NMDA foi diagnosticada e uma tomografia computadorizada de abdome revelou um tumor anexial à esquerda. Descrevemos o primeiro relato de caso de paciente com encefalite antirreceptor de NMDA submetida ao bloqueio de plano transverso abdominal (PTA) bilateral como única anestesia para remoção de tumor ovariano. Também discutimos as questões anestésicas associadas à encefalite antirreceptor de NMDA. Como a descoberta e a remoção do tumor são o foco do tratamento inicial nesse grupo de pacientes, os anestesiologistas encontrarão mais desses casos no futuro próximo. Keywords: Anti-N-methyl-d-aspartate receptor encephalitis, Transversus abdominis plane block, Anti-NMDA receptor encephalitis and anesthesia, Palavras-chave: Encefalite antirreceptor de N-metil-d-aspartato, Bloqueio do plano transverso abdominal, Encefalite antirreceptor de NMDA e anestesi

Anesthesia in anti-N-methyl-D-aspartate receptor encephalitis - is general anesthesia a requisite? A case report

Abstract Anti-N-methyl-D-aspartate receptor encephalitis is a recently described neurological disorder and an increasingly recognized cause of psychosis, movement disorders and autonomic dysfunction. We report 20-year-old Chinese female who presented with generalized tonic-clonic seizures, recent memory loss, visual hallucinations and abnormal behavior. Anti-N-methyl-D-aspartate receptor encephalitis was diagnosed and a computed tomography scan of abdomen reviewed a left adnexal tumor. We describe the first such case report of a patient with anti-N-methyl-D-aspartate receptor encephalitis who was given a bilateral transversus abdominis plane block as the sole anesthetic for removal of ovarian tumor. We also discuss the anesthetic issues associated with anti-N-methyl-D-aspartate receptor encephalitis. As discovery of tumor and its removal is the focus of initial treatment in this group of patients, anesthetists will encounter more such cases in the near future

Comparison of clinical performance of size 1.5 Supreme™ LMA and Proseal™ LMA among Asian children: a randomized controlled trial

To date, most of the studies on safety and efficacy of supraglottic airway devices were done in Caucasian patients, and the results may not be extrapolated to Asian patients due to the different airway anatomy. We conducted this study to compare Supreme™ LMA (SLMA) and Proseal™ LMA (PLMA) size 1.5 in anaesthetized children among an Asian population. This prospective randomized clinical trial was conducted in a tertiary teaching hospital from September 2013 until May 2016. Sixty children, weighing 5–10 kg, who were scheduled for elective surgery under general anaesthesia were recruited and completed the study. Patients were randomly assigned to have either SLMA or PLMA as the airway device for general anaesthesia, and standard anaesthesia protocol was followed. The primary outcome measured was the oropharyngeal leak pressure (OLP). The rate of successful insertion, insertion time, fibreoptic view of larynx and airway complications for each device were also assessed. There were no statistically significant differences between SLMA and PLMA size 1.5 in oropharyngeal leak pressure [19.1 (± 5.5) cmH2O vs. 19.8 (± 4.5) cmH2O, p = 0.68]. Secondary outcomes including time to insertion [20.8 (± 8.3) vs. 22.1 (± 8.3) s, p = 0.57], first attempt success rate for device insertion, fibreoptic view of larynx, and airway complications were also comparable between the two devices. We found that all the patients who had a failed device insertion (either PLMA or SLMA) were of a smaller size (5–6.2 kg). The oropharyngeal leak pressure of the SLMA 1.5 was comparable with the PLMA 1.5, and both devices were able to maintain an airway effectively without significant clinical complications in anaesthetized children from an Asian population

Evaluation of the quality of acute pain management in a pediatric surgical setting: Validation of a parent proxy modified version of the revised American Pain Society Patient Outcome Questionnaire

Background: Effective pain management involves a cycle of continual pain assessment, good pain control strategies, and assessment of a standard quality improvement measures. A validated questionnaire that focuses on the quality of postoperative pain management in pediatric surgical patients and parental satisfaction on pain treatment is lacking. We, therefore, modified the revised American Pain Society Patient Outcome Questionnaire to evaluate the quality of postoperative pain management in a pediatric surgical setting. The primary aim of this study was to validate the modified version of revised American Pain Society Patient Outcome Questionnaire. Methods: Parents whose children aged below 12 years and were scheduled for elective surgery in a teaching hospital, were approached to participate in this survey. The reliability of the modified version of revised American Pain Society Patient Outcome Questionnaire was evaluated using Cronbach's alpha test, while the construct validity was assessed with a principal component analysis using a varimax rotation. The parental satisfaction with pain treatment received was measured. Results: A total of 108 parents completed the questionnaire. The internal consistency of the questionnaire shows a Cronbach's alpha of 0.798. Principal component analysis revealed a four-factor structure of the 12 items which explained 69.7% of the total variance. The factors are “Interference of sleep and activity,” “Pain severity and drowsiness,” “Perception of care,” and “Adverse effects,” respectively. Our study showed that this questionnaire is a valid and reliable measure for “Interference of sleep and activity” and “Pain severity and drowsiness” factors, but not for “Perception of care” and “Adverse effects.” The results for “Perception of care” and “Adverse effects,” therefore, should be reported as individual items instead of total score. The parental satisfaction with pain treatment given was good (median 8.0; IQR 3.0). Conclusion: The modified version of revised American Pain Society Patient Outcome Questionnaire is a feasible and easy instrument to administer. The questionnaire can be used to obtain feedback from parents about the outcomes and experiences of pain management and is helpful in continuous quality evaluation and improvement in the postoperative care in a pediatric setting