Knowledge, attitude and practice of doctors regarding perioperative tobacco smoking intervention in surgical based discipline in IIUM Medical Centre

Introduction: Surgery provides an exceptional chance for smoking cessation and apparently surgeons can play an important role in tobacco control. Tobacco intervention in surgical patients benefited them both in the short-term and longterm health outcome. Unfortunately, little is known about the knowledge, attitudes and practices of Malaysian surgeon regarding peri-operative tobacco smoking interventions which triggers this study. Materials and Methods: A survey of written questionnaires was conducted on medical doctors in the surgical based discipline at the International Islamic University Malaysia Medical Centre. Results: The survey response rate was 100%, and 6.7% of respondents themselves were current smoker, 23.3% were former smoker. A high proportion of respondents had accurate perceptions of peri-operative and long-term health risks of smoking. However, most of them also knew how to counsel about smoking or help patients get the help they needed to quit. Majority (93.3%) of them frequently or almost always asked about smoking status; 56.7% advised about the health risk of tobacco use; 80.0% advised patients to stop smoking peri-operatively and 60.0% advised patients to quit smoking permanently. Compared with non-smokers, smokers were significantly less likely to advice about the health risks of smoking and quitting. Not only that, most of the respondents were willing to learn about peri-operative interventions and spend an extra 5 min to help patients quit smoking. Conclusions: Majority of the respondents poised adequate knowledge of health risks of smoking, strong perception of responsibilities, and willingness to participate in tobacco control, IIUM Medical Centre doctors actually play a significant role in tobacco control in which could improve peri-operative outcomes and promote long-term health

Inadvertent puncture of right vertebral artery during central venous line catheter insertion

The use of ultrasound has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this report, we recommend the structures approach for US-guided to insert venous access for clinical practice. To achieve the best skill for CVC placement, The knowledge from anatomic landmark techniques and knowledge from US-guided CVC placement need to be combined and integrated. 59 years old lady, planned for total abdominal hysterectomy for pelvic tumour excision. Anticipate massive bleeding with major fluids shift during intraoperative, invasive monitoring with CVC was inserted preoperative at right internal jugular vein. The procedure of insertion was done using US-guided with out-of-plane method. While connected to CVP monitoring noted to have arterial wave. Decided to keep the central venous line in-situ and referral to radiologist for imaging was arranged. CT angiogram's findings of a catheter were seen to transverse the right internal jugular vein through-and-through and seen to lie within the right vertebral artery coursing into the right subclavian artery. No evidence of carotid artery injury. Referred to intervention radiology and vascular surgery team for the best method of removal the central line catheter. Removal of CVC for inadvertent injury to right verterbral artery under guided contrast study by intervention radiologist. The case illustrates the importance of ultrasound-guided CVL insertion

The impact of educational intervention on attitude towards organ donation among healthcare workers in five hospitals in Malaysia

Introduction : The attitude of healthcare workers (HCW) are essential in influencing organ donation rates. Objective : The study aimed to assess the impact of educational intervention on attitudes towards organ donation among HCW. Methodology : A questionnaire-based interventional study was conducted among 458 HCW from five hospitals in Malaysia. A 26-item self-administered questionnaire was distributed online as a pre-intervention test. Afterwards, the respondents went through a website-based educative materials about organ donation and answered the same questionnaire again. Results : A total of 345 (75.3%) respondents completed the tests. Their attitude towards organ donation was positive pre-intervention. Following it, respondents expressed increase willingness to donate organs (P = 0.008) and their relatives’ organs (P <0.001); were more willing to adopt organ donation as part of the end-of-life care (P = 0.002) and were more comfortable to talk to relatives about organ donation (P = 0.001). There was increased willingness to admit patients to the Intensive Care unit for facilitating organ donation (P = 0.007); to employ the same resources to maintain a potential brain-dead donor (P <0.001); and to support organ donation if they or their relatives have end-stage organ failure (P = 0.008). However, there was increased negative attitude regarding association between organ donation with healthcare failure (P = 0.004), and with pain (P = 0.003). The positive attitude scores were higher following the intervention (P <0.001). Conclusion : An educational website-based intervention was able to improve HCW attitudes towards organ donation although some potential improvements are required

The Impact of educational intervention on attitude toward organ donation among health care workers in Malaysia

Background. The attitudes of the health care workers (HCWs) are essential in influencing organ donation rate. The aim of this study was to assess the effects of an educational intervention on attitudes toward organ donation among HCWs. Methods. A questionnaire-based interventional study was conducted with 458 HCW from 5 hospitals in Malaysia. A 26-item self-administered questionnaire was distributed online as a pre- intervention test. Respondents then went through website-based educational materials followed by a post-intervention questionnaire. Results. A total of 345 (75.3%) respondents completed the tests. Their attitude toward organ dona- tion was positive preintervention. After the intervention, respondents expressed an increase willingness to donate their own organs (P = .008) and their relatives’ organs (P < .001) after death; were more willing to adopt organ donation as part of end-of-life care (P =.002); were more comfortable talking to relatives about organ donation (P =.001); and expressed an increase consideration to execute the action at any time (P =.001). There was increased willingness to admit to the intensive care unit for facilitating organ donation (P =.007); to employ the same resources to maintain a potential brain-dead donor (P < .001); and to support organ donation in case they or their relatives were diagnosed with end-stage organ failure (P =.008). However, there was an increase in negative attitudes regarding the association between organ donation with health care failure (P =.004) and with pain (P =.003). Posi- tive attitude scores were higher after the intervention (P < .001). Conclusion. An educational website-based intervention was able to improve the attitudes of HCWs toward organ donation

Dynamic changes of plasma neutrophil gelatinase-associated lipocalin predicted mortality in critically ill patients with systemic inflammatory response syndrome

Background and Aims: About 50% of patients admitted to the Intensive Care Unit have systemic inflammatory response syndrome (SIRS), and about 10%-20% of them died. Early risk stratification is important to reduce mortality. Plasma neutrophil gelatinase-associated lipocalin (NGAL) is increased by inflammation and infection. Its ability to predict mortality in SIRS patients is of interest. We evaluated the ability of serial measurement of NGAL for the prediction of mortality in critically ill patients with SIRS. Materials and Methods: This is a secondary analysis of a single-center, prospective, observational study. Patients who fulfill the SIRS criteria were recruited in the study. Delta NGAL at 24 and 48 h (ΔNGAL-24 and ΔNGAL-48) was defined as 24 and 48 h NGAL minus day 1 NGAL; NGAL clearance (NGALc) was defined as percentage of ΔNGAL over day 1 NGAL. The primary outcome of the study is in-hospital mortality. Results: A total of 151 patients were analyzed, of which 53 (35%) died. Nonsurvivors were older (51 vs. 45, P = 0.03) and had higher Sequential Organ Failure Assessment (9 ± 7 vs. 7 ± 4, P = 0.02) and Simplified Acute Physiology Score II (47 ± 15 vs. 40 ± 15, P = 0.01) scores as compared to survivors. NGAL concentrations over 3 days were higher in nonsurvivors compared to survivors (repeated measures analysis of variance, P = 0.02). Day 1 NGAL, ΔNGAL-24, and NGALc-24 were not independently predictive of mortality. However, day 3 NGAL, ΔNGAL-48, and NGALc-48 were predictive after adjusted for age and severity of illness (odds ratio 9.1 [1.97-41.7]). Conclusions: NGAL dynamics over 48 h independently predicted mortality in critically ill patients with SIRS. This could assist clinicians in risk stratification of this group of high-risk patients

The utility of the creatinine excretion to production ratio and the plasma creatinine and cystatin C based kinetic estimates of glomerular filtration rates in critically ill patients with sepsis

Introduction: Creatinine kinetics denotes that under steady state conditions creatinine production (G) will equal creatinine excretion rate (E). The glomerular filtration (GFR) is impaired when excretion is less than production. The kinetic estimate of GFR (keGFR) was and E/G ratio were proposed as a more accurate estimate of GFR in the acute settings with rapidly changing kidney function. We evaluated keGFR and E/G to diagnose AKI, predict recovery, and predict death or dialysis. Materials and Methods: A prospective observational study of critically ill patients. Inclusion criteria were patients > 18 years old with sepsis, defined as clinical infection with an increase in SOFA score >2 and plasma procalcitonin >0.5ng/ml. Plasma creatinine and Cystatin C were measured on ICU admission and 4 hours later, and their keGFR calculated. Urine creatinine and urine output were measured over 4-hours to calculate the E/G ratio. Results: A total of 70 patients were recruited, of which 49 (70%) had AKI. Of these, 33 recovered within 3 days, and 15 had composite outcome of death or dialysis. Day 1 keGFRCr and keGFRCysC discriminated AKI from non-AKI with AUCs of 0.85 (95% Confidence interval: 0.74 to 0.96), and 0.86 (0.76 to 0.97) respectively. The E/G ratio predicted of AKI recovery (AUC 0.81 (0.69 to 0.97)). The keGFRs were not predictive of death or dialysis, whereas E/G was predictive (AUC of 0.76 (0.63 to 0.89). Conclusion: keGFR was strongly diagnostic of AKI. The E/G ratio predicted AKI recovery and composite outcome of death and dialysis

Prevalence of acute kidney injury and sepsis in a Malaysian intensive care setting

Introduction Acute Kidney Injury (AKI) is common in patients admitted to the intensive care unit, occurring in 30 to 60% of patients. The high incidence of AKI in our population may be attributed to sepsis. Sepsis is the leading cause of ICU admission. The Malaysian Registry of Intensive Care (MRIC), an annual ICU audit performed in all Malaysian ICUs. This registry serves as an excellent avenue to explore the incidence of septic AKI in our local ICU. Methods This retrospective cohort study extracted de-identified data from the Malaysian Registry of Intensive Care (MRIC) for patients admitted to Hospital Tengku Ampuan Afzan between January and December 2014. The study was registered under the NMRR (NMRR-14-1938-23183) and approved by the ethics committee. AKI was defined as doubling of serum creatinine from baseline value. Results A total of 1059 ICU admissions were analysed. Of these 230 (21.7%) had AKI and 253 (23.9%) had sepsis within 24 hours of admission. Patients with AKI were older and had higher severity of illness compared to those without AKI (p<0.0001). Diabetes mellitus, chronic renal failure and hypertension were more common in patients with AKI. Twenty percent of patients received dialysis, and 23% died. Of those who survived, AKI patients had longer duration of mechanical ventilation, length of ICU and hospital stay (p<0.0001). Seventy-three percent (n=168) of patients with sepsis had AKI (p<0.0001). Conclusions AKI is common in our ICU, with higher morbidity and mortality. Risk factors of AKI includes age, severity of illness, the presence of sepsis and pre-existing diabetes mellitus, chronic renal failure, and hypertension. Future analysis will explore a larger cohort of data involving four tertiary hospitals over a five-year duration

Acute kidney injury in Malaysian intensive care setting: incidences, risk factors and outcome

Introduction: Acute Kidney Injury (AKI) is common in the intensive care unit (ICU) with high risk of morbidity and mortality. The high incidence of AKI in our population may be attributed to sepsis. We investigated the incidence, risk factors and outcome of AKI in four tertiary Malaysian ICUs. We also evaluated its association with sepsis. Materials and Methods: This retrospective cohort study extracted de-identified data from the Malaysian Registry of Intensive Care in four Malaysian tertiary ICUs between January 2010 and December 2014. The study was registered under the NMRR and approved by the ethics committee. AKI was defined as twice the baseline creatinine or urine output < 0.5 ml/kg/h for 12 hours. Results: Of 26,663 patients, 24.2% had AKI within 24 hours of admission. Patients with AKI were older and had higher severity of illness compared to those without AKI. AKI patients had longer duration of mechanical ventilation, length of ICU and hospital stay. Age, SAPS II Score, and the presence of sepsis and preexisting hypertension, chronic cardiovascular disease independently associated with AKI. 32.3% had sepsis. Patients with both AKI and sepsis had highest risk of mortality (RR 3.43 (3.34 to 3.53)). Conclusions: AKI is common in our ICU, with higher morbidity and mortality. Independent risk factors of AKI include age, severity of illness, sepsis and preexisting hypertension, chronic cardiovascular disease. AKI independently contributes to mortality. The presence of AKI and sepsis increased the risk of mortality by three times

Plasma cystatin C and estimates of glomerular filtration rate using cystatin C independently diagnosed acute kidney injury in critically ill patients with sepsis

Introduction: Plasma Cystatin C (CysC) is as an early functional marker for acute kidney injury. Estimates of glomerular filtration rate using CysC (eGFRCysC) has been used in some clinical setting. We evaluated the utility of CysC and eGFRCysC in diagnosing AKI and predicting death in critically ill patients with sepsis. Methods: This is an interim analysis of single centre, prospective observational study of critically ill patients. Inclusion criteria were patients older than 18 years old with sepsis and procalcitonin > 0.5ng/ml. Plasma creatinine and CysC were measured on admission, and eGFRCysC was calculated. AKI was defined based on the plasma creatinine criteria of the KDIGO guideline. Results: Thirty one patients were recruited so far, of which 13 (41.9%) had AKI and six died. CysC were higher in patients with AKI versus No AKI (p<0.001), and correspondingly, eGFRCysC were lower (p=0.006). CysC and eGFRCysC on ICU admission diagnosed AKI with an AUC of 0.88 (0.72 to 1.00), and 0.79 (0.62 to 0.96), respectively. Both did not predict death (AUC 0.59 (0.31 to 0.87) and 0.59 (0.31 to 0.86), respectively). After adjusting for age and SOFA score, both CysC and eGFRCysC independently diagnosed AKI (OR 13 (1.5 to 115) and 1.03 (1.01 to 1.06), respectively). The ideal cut-off point for diagnosing AKI for CysC was 1.5 mg/dl (84% sensitivity and 89% specificity) and for eGFRCysC 77 ml/min (72% sensitivity and 84% specificity) Conclusions: Plasma CysC and its estimated GFR independently diagnosed AKI in critically ill patients with sepsis. We suggest an ideal cut-off points of 1.5 mg/dl and 77 ml/min that can be used in the clinical setting in this cohort of patients

Serial evaluation of sequential organ failure assessment score in predicting 1-year mortality in critically Ill patients

Introduction: The prediction of long-term prognosis or outcome of critically ill patients in the intensive care unit (ICU) is important for prognostication and administration purposes. The Sequential Organ Failure Assessment (SOFA) score was developed in order to estimate organ failure in patients with sepsis. Organ failures have been associated with mortality and hence SOFA score has been validated as an outcome measure. To the best of our knowledge, the association of SOFA, and serial SOFA score with 1-year mortality has not been well established. Materials and method: This was a retrospective observational cross sectional study using the existing record of patients admitted to the general ICU at the Sultan Ahmad Shah Medical Centre from the 1st June 2017 to the 30th May 2018. Data was collected from daily clinical charts and medical records of patients. SOFA score on day-1, day-3, day-3, and on discharge were recorded and subsequently delta SOFA was calculated. Results: Data from a total of 120 patients were collected. SOFA score within 3 days of admission predicted 1-year mortality, with the highest prediction for on SOFA score on discharge from ICU. Serial SOFA score measured within 24 hours (day-1 to day-2) and 48 hours (day-1 to day-3) did not predict mortality; however, delta SOFA involving SOFA on discharge did. Cardiovascular and renal scores were the most significant individual component of SOFA score that contributed to 1-year mortality. Conclusion: SOFA score measured on discharge from ICU plays a key important factor in contributing for the prediction of 1-year mortality. Cardiovascular and renal scores were the most significant component that warrant risk stratification measures using the parameters