Examination in the COVID Era, tackling the uncertainties

In the earlier days of COVID pandemic, the format of the Anaesthesiology Conjoint Board Part 1 Examination has to be changed to suit the pandemic standard operating procedures. The article describes the challenges faced by University to organise examination during COVID era

Prognostic utility of monocyte distribution width in critically ill patients

Background Sepsis is one of the leading causes of intensive care unit (ICU) admission and mortal- ity in Malaysia. Delayed recognition of sepsis is associated with increased morbidity and mortality. Monocyte distribution width (MDW) represents the width of a set of monocyte volume values, which increases as infection progress in severity. Its mea- surement is one of the haematologic parameter of complete blood count, hence, it does not incur added cost and is widely available. We evaluated the prognostic ac- curacy of MDW. Methods This was a prospective cohort study of 100 patients who are grouped into sepsis and non-sepsis according to the Sepsis-3 definition. This study enrolled adults, age 18 years and above, whose evaluation included a complete blood count with differ- ential upon admission to ICU. Exclusion criteria included patient refusal to join the study, readmission to ICU within 12 hours and prior study enrolment. MDW and WBC were collected on admission to ICU and for subsequent 3 days. The study had ob- tained approval from the IIUM Research Ethics Committee (Number 2020-079). Results A total of 100 patients were recruited in the study. Twenty-three patients (23%) died within 30 days of ICU admission. MDW were predictive of 30-day mortality with a cut-off point of 25.97. Patients with on admission MDW higher than this cut-off point were more likely to die with 30 days compared to those with lower value. WBC on admission and throughout 3 days were not predictive of 30-day mortality. Conclusion MDW is an effective prognosis tool of mortality upon admission to ICU. As part of the differential in CBC, MDW makes a cost effective and widely available test at present. Early prediction of death allows for risk stratification for patients admitted to the ICU

Physiological and psychological effects of listening to Holy Quran Recitation in the Intensive Care Unit patients: a systematic review

Stress and anxiety are common among intensive care unit (ICU) patients especially those who are on mechanical ventilation. Non-pharmacological interventions such as music and prayer are recommended because they are opioid sparing, easy to provide, cheap and safe. There is a growing body of evidence on the effects of Holy Quran Recitation (HQR) in reducing stress and anxiety in critically ill Muslim patients. The aim of this review is to evaluate the physiological and psychological effects of HQR specifically in ICU setting. This review was performed on articles published between 2007 and 2018. Extensive search was done using PubMed, ISI Web of Knowledge, Scopus and Google Scholar. Systematic review articles are also assessed and relevant literatures are hand searched based on reference lists and citations made in key publications. Studies related to HQR which were done outside adult ICU setting were excluded. A total of nine articles are included in the final list for detail analysis. Findings of this review revealed six studies with significant results in improving stress responses, hemodynamic stability and conscious levels. HQR is a potential non-pharmacological tool to reduce stress and can also be used as auditory stimulus to improve conscious level in comatose patients. More studies in this area are recommended aiming for low risk of bias, appropriate calculation of sample size and adequately powered to detect significant outcomes

Physiological and psychological of listening to Holy Quran recitation in the intensive care unit patients: a systematic review

Stress and anxiety are common among intensive care unit (ICU) patients especially those who are on mechanical ventilation. Non-pharmacological interventions such as music and prayer are recommended because they are opioid sparing, easy to provide, cheap and safe. There is a growing body of evidence on the effects of Holy Quran Recitation (HQR) in reducing stress and anxiety in critically ill Muslim patients. The aim of this review is to evaluate the physiological and psychological effects of HQR specifically in ICU setting. This review was performed on articles published between 2007 and 2018. Extensive search was done using PubMed, ISI Web of Knowledge, Scopus and Google Scholar. Systematic review articles are also assessed and relevant literatures are hand searched based on reference lists and citations made in key publications. Studies related to HQR which were done outside adult ICU setting were excluded. A total of nine articles are included in the final list for detail analysis. Findings of this review revealed six studies with significant results in improving stress responses, hemodynamic stability and conscious levels. HQR is a potential nonpharmacological tool to reduce stress and can also be used as auditory stimulus to improve conscious level in comatose patients. More studies in this area are recommended aiming for low risk of bias, appropriate calculation of sample size and adequately powered to detect significant outcomes

Ultrasonographic method as confirmatory test for feeding tube placement in mechanically ventilated patients

Objective: Nasogastric feeding tube placement is common procedure in intensive care units (ICU). Although the incidence of misplacement is rare but it is dreadful for the patients. This study objective is to estimate the accuracy of ultrasonography method in confirming feeding tube placement. Methods: 80 ICU patients were included, feeding tube placement will be assessed by ultrasonography through 3 points. First point, visualization of feeding tube in cervical esophagus at left anterolateral of neck. Second point, visualization of feeding tube at sub-xiphoid or left upper abdominal quadrant. Third point, injection of only air and look for dynamic fogging using color Doppler flow. Presence of feeding tube in any sonographic assessment points consider in-situ. Final confirmation will be assessed using chest X-ray (CXR). Time for each method will be recorded. Results: Total 78 patient’s feeding tube placement were in-situ, confirmed by chest X-ray. Sensitivity, specificity of cervical esophagus assessment was 68%/0%, subxiphoid 31%/100%, and dynamic fogging 97%/100% respectively. Combination of cervical esophagus assessment with sub-xiphoid or dynamic fogging does improve sensitivity up to 100%, but adversely affect specificity down to 0%. Combination of Sub-xiphoid and dynamic fogging yield 100% sensitivity and 100% specificity. Accuracy of each ultrasound method were not affected by gender or body mass index (BMI). Entire sonographic procedure took 3 minutes (+ 0.8) while chest X-Ray took 61 minutes (+ 87). Conclusions: Sub-xiphoid and dynamic fogging sonography assessment were valuable in confirming placement of feeding tube in-situ, however cervical esophagus assessment can be helpful in identify feeding tube pass through esophagus but not final in-situ placement. Sonography methods carry the potential to be reliable alternative method in feeding tube placement, however larger studies are required to strengthen evidence

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

Misplacement of the nasogastric tube into the anterior neck potential space

Nasogastric tube insertion is a very common procedure performed in intensive care settings which require a basic skill. In mechanically ventilated patients, the blind technique may lead to inadvertent placement of the tube into the lung even when the endotrachial cuff was inflated. The preferred technique is using a laryngoscopy for direct vision during the insertion. The gold standard of NGT placement confirmation in mechanically ventilated patient is with chest radiograph. Other clinical confirmation tests are not as reliable in intubated patients. A 44 year old lady came in with huge anaplastic carcinoma of the thyroid with compression symptoms. Otherwise, she had an unremarkable other medical problem. She underwent palliative debulking surgery to remove part of the tumor. The tumor was very aggressive, few days postoperatively it caused tracheal erosion with subcutaneous emphysema around the neck and upper chest. Urgent tracheostomy was done. Following this operation, NGT was reinserted. The nasogastric insertion was uneventful and the placement of the tube was confirmed by aspiration of gastric content and syringe test. Enteral feeding was resumed afterward. A few hours later the patient complained of neck pain and tense swelling developed on her neck and upper chest. Whitish secretion was noted to seep out around the tracheostomy wound. Enteral feeding was withheld and chest radiograph showed coiled NGT in the potential space of the anterior neck. The NGT was removed and surgical debridement was performed to evacuate the milk contamination. The case illustrates the importance of radiological confirmation of NGT placement in the ventilated patient

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

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

Effect of colloid on acid-base balance during colorectal surgery: balanced (tetraspan) versus non balanced (venofundin) hydroxyethyl starch

This prospective, randomized, controlled study was carried out to compare the usage of balanced and non balanced hydroxyethyl starch during elective colorectal surgery in term of changes in acid-base balance and renal profile in the immediate and early postoperative period. Thirty informed, consented, adult patients with ASA I-II, undergoing open colorectal surgery with duration of more than three hours were recruited after excluding those with significant cardiac, liver or renal diseases, and those with allergy to the starches. These patients were randomly allocated into two study groups. The Balanced group received an intraoperative fluid regimen that consisted of Hartmann’s solution and balanced 6% hydroxytehyl starch (Tetraspan®). The Non Balanced group were given Hartmann’s solution and saline-based 6% hydroxyethyl starch (Venofundin®). Patients were kept hemodynamically stable and normovolumia throughout the operation by giving boluses of the study fluids as volume replacement therapy. Biochemical indices for acid base balance and renal profile were reviewed at two endpoints: immediately post operation (at 1-hour) and early post operation (at 6-hour). There were no difference at immediate and early post operation respectively, noted in term of base excess (p = 0.733 , p = 0.507 ) , chloride (p = 0.483, p = 0.401), lactate (p = 0.477, p = 0.993), urea (p = 0.244, p = 0.190) and creatinine (p = 0.578, p = 0.323) between both groups