Comparison of passive warming with heat-band versus resistive heating blanket for prevention of inadvertent perioperative hypothermia in laparotomy for gynaecologic surgeries

Introduction: Inadvertent perioperative hypothermia (IPH) (defined as core body temperature <35.5°C) is still a common problem despite advancement in a variety of warming systems. In our centre, a common approach to patient warming is by resistive heating blanket, a costly device. To find a cost-effective alternative to patient warming, a group of local researchers innovated a new passive warming device called Heat-Band. We compared the efficacy of the Heat-Band with resistive heating blanket in preventing IPH and its complications during laparotomy for gynaecologic surgeries. Methods: Thirty-two patients undergoing laparotomy for gynaecologic surgeries under combined general-epidural anaesthesia, with expected duration of surgery between two to four hours, were randomized to receive either Heat-Band or resistive heating. In both groups, the warming devices were applied immediately after placement of epidural catheter and induction of general anaesthesia. Core body temperatures measured at several perioperative timepoints in the two groups were compared. Time to extubation, incidence of post-anaesthesia shivering and intraoperative blood loss were also measured and compared between groups. Results: There was no significant difference between the two groups in terms of demographic, anaesthesia and surgical details. The core body temperatures were comparable between the two groups at preoperative period, immediately after induction of anaesthesia, skin incision, one hour after incision, complete skin closing, at extubation, upon arrival to recovery, and one hour postoperatively. There were also no significant differences between the two groups in terms of time to extubation, incidence and intensity of post-anaesthesia shivering and intraoperative blood loss. Neither device failures (as indicated by patients who developed IPH in recovery) nor incidence of adverse effects from warmer usage have been reported in both groups. Conclusion: Heat-Band results in comparable maintenance of core body temperature with the resistive heating in the perioperative period of laparotomy for gynecologic surgeries. It also results in comparable recovery from anaesthesia, incidence of shivering and intraoperative blood loss with the resistive heating. We concluded that Heat-Band is a cost-effective alternative to active warming during anaesthesia and surgery of intermediate duration

Validation of the 28-day mortality prognostic performance of the modified nutrition risk in critically ill score in a Malaysian intensive care unit

Introduction: The mNUTRIC score is a nutritional assessment tool to identify critically ill patients with high nutritional risk who could benefit from nutritional interventions. This study was conducted to validate the 28-day mortality prognostic performance of the mNUTRIC score in a Malaysian intensive care unit (ICU). Methods: This was a retrospective cohort study of adult patients who were consecutively admitted to the ICU from January 2017 to December 2018 for >24 hours. Data were collected on variables required to calculate the mNUTRIC score. Patients with mNUTRIC score ≥5 points were considered to be at high nutritional risk. Main outcome was 28- day mortality from all causes; ICU length of stay (LOS) and prolonged mechanical ventilation (MV) (>2 days) were secondary outcomes. Results: From a total of 432 admissions, 382 (88.4%) patients fulfilled the study criteria. Seventy-seven (20.2%) of these patients were at high nutritional risk. They had longer mean ICU LOS (7.1±7.5 days versus 4.2±4.0 days, p=0.001), greater proportion of prolonged MV (57.1% versus 14.4%, p<0.001) and higher 28-day mortality (44.2% versus 10.2%, p<0.001) compared to patients with low mNUTRIC score (≤4 points). High mNUTRIC score predicted 28-day mortality with area under the curve (AUC) of 0.797 (95% confidence interval: 0.738-0.856). Conclusion: High mNUTRIC score was associated with a higher 28-day mortality. The prognostic performance for 28-day mortality of the mNUTRIC score is clinically valid as indicated by AUC >0.7 and is comparable to the results of other validation studies. In addition, patients with high mNUTRIC score had increased ICU LOS and prolonged MV. Key words: Nutritional status, critically ill, mortalit

Point-of-care procalcitonin guidance to reduce antibiotic use in critically ill patients: a randomized controlled trial

Introduction: Antibiotic therapy is of great importance in sepsis but prolonged duration can add to the emergence of antibiotic resistance. We aimed to examine whether point-of-care (POC) procalcitonin (PCT) guidance can safely reduce the duration of antibiotic use in infected critically ill patients. Materials and Methods: Eighty adult patients admitted to or acquired sepsis in the intensive care unit (ICU) were enrolled in this randomized controlled trial. Patients were allocated to either POC PCT-guided intervention arm (n=40) or the control arm, in which antibiotic therapy followed local guidelines (n=40). In the PCT-guided arm, antibiotic treatment was discontinued if clinical signs of infection improved and the PCT concentration decreased by >80% of its peak value, or when it reaches a value of <0·5 g/L. Results: The mean duration of antibiotic use for PCT arm was 6.4 (SD 2.3) days compared to 9 (SD 4.3) days in the control arm (p=0.004). In the first 30 days after being assigned to a group, the proportion of patients who received a repeated course of systemic antibiotics was 33% in the PCT arm vs 38.1% in the control arm (p=0.757). Mean length of stay in the ICU was 8.4 (SD 5.3) days in the PCT arm vs 10.4 (SD 12.3) days in the control arm (p=0.404). Mortality at 30 days was 22.5% in the PCT-arm vs 25% in the control arm (p<0.0001). Conclusion: POC PCT guidance stimulates reduction of duration of antibiotic use in ICU, accompanied by a significant decrease in mortalit

Model-based insulin sensitivity as a new biomarker of sepsis diagnosis in the intensive care unit

Introduction: Currently, there is a lack of real-time biomarker to diagnose sepsis. Insulin sensitivity (SI) may be determined in real-time using mathematical glucose-insulin models, but its effectiveness as a diagnostic test of sepsis remains unexplored. We aimed to explore the diagnostic value of model-based SI as a new biomarker of sepsis in a mixed cohort of diabetic and non-diabetic patients newly admitted to the intensive care unit (ICU). Materials and methods: In this cross-sectional study, we analysed SI levels derived from the Intensive[1]Control-of-Insulin-Nutrition-Glucose model in septic (n=45) and non-septic (n = 41) patients upon their ICU admission. The diagnostic value of model-based SI for sepsis was determined through analysis of the area under the curve (AUC) of the receiver operating characteristic curve. Results: Baseline SI levels were significantly lower in patients with sepsis than those without sepsis (0.560 (SD=0.676) vs. 1.097 (SD=1.473) x 10-4 L/mU/min, P = 0.037). However, the AUC of 0.588 revealed that model-based SI was a poor diagnostic test of sepsis in the mixed cohort of diabetics and non-diabetics. In a separate analysis among the non-diabetics (n=19), model-based SI predicted sepsis with clinically valid performance (AUC 0.911). Conclusion: Presence of sepsis significantly reduced SI in the critically ill patients but a low SI could predict sepsis only in the non-diabetic cohort

Awake Nasal Fiberoptic Intubation in Diffuse Para-pharyngeal Abscess

This is a case report on awake fibreoptic intubation for a patient with a deep neck space infection. Intubation in this group of patients is considered difficult. It is challenging to anaesthesiologists, emergency physicians and otorhinolaryngologists because there is no consensus for airway management in these patients. We present a 30-year-old gentleman with swelling over the right cheek, difficulty breathing and severe trismus. He had a history of toothache one month prior to admission. Upon clinical examination, there was a diffuse swelling over the right mandible. Other examinations were unremarkable. Provisional diagnosis of a right para-pharyngeal abscess was made secondary to a possible infected right lower 3rd molar, with a differential diagnosis of a right parotid abscess with para-pharyngeal extension. Radiological assessment using computed tomography (CT) of the head and neck region showed an abscess over the right para-pharyngeal area, soft palate and right submandibular region. The narrowest part of the airway was at the region posterior to the soft palate, measuring approximately 1 cm. All staff and equipment were prepared for intubating a difficult airway. The patient was transferred to the control environment (operation theatre) for intubation. Awake nasal fibreoptic intubation (AFOI) was successfully performed for this patient using intravenous dexmedetomidine alone as the sedative

The combined use of interleukin-6 with serum albumin for mortality prediction in critically ill elderly patients: the interleukin-6-to-albumin ratio

Background: The association between interleukin-6 (IL-6) and serum albumin (ALB) with mortality in critically ill elderly patients, either as stand-alone biomarkers or in combination, has been scarcely reported. We, therefore, aimed to investigate the prognostic value of the IL-6-to-albumin ratio in this special population. Patients and methods: This was a cross-sectional study conducted in the mixed intensive care unit (ICU) of two university-affiliated hospitals in Malaysia. Consecutive elderly patients (aged above or equal to 60 years) admitted to the ICU, who underwent simultaneous measurement of plasma IL-6 and serum ALB, were recruited. The prognostic value of the IL-6-to-albumin ratio was assessed by analysis of the receiver-operating characteristic (ROC) curve. Results: A total of 112 critically ill elderly patients were recruited. The outcome of all-cause ICU mortality was 22.3%. The calculated IL-6-to-albumin ratio was significantly higher in the non-survivors compared to the survivors {14.1 [interquartile range (IQR), 6.5–26.7] vs 2.5 [(IQR, 0.6–9.2) pg/mL, p <0.001]}. The area under the curve (AUC) of IL-6-to-albumin ratio for discrimination of ICU mortality was 0.766 [95% confidence interval (CI), 0.667–0.865, p <0.001] which was slightly higher than that of IL-6 and albumin alone. The ideal cut-off value of the IL-6-to-albumin ratio was above 5.7 with a sensitivity of 80.0% and specificity of 64.4%. After adjusting for severity of illness, the IL-6-to-albumin ratio remained as an independent predictor of ICU mortality with an adjusted odd ratio of 0.975 (95% CI, 0.952–0.999, p = 0.039). Conclusion: The IL-6-to-albumin ratio offers a slight improvement in mortality prediction than either of its constituent individual biomarkers and as such, it may be a potential tool to aid in the prognostication of critically ill elderly patients although this requires further validation in a larger prospective study

Levels and diagnostic value of model-based insulin sensitivity in sepsis: a preliminary study

Background and Aims: Currently, there is a lack of real time metric with high sensitivity and specificity to diagnose sepsis. Insulin sensitivity (SI) may be determined in real time using mathematical glucose insulin models; however, its effectiveness as a diagnostic test of sepsis is unknown. Our aims were to determine the levels and diagnostic value of model based SI for identification of sepsis in critically ill patients. Materials and Methods: In this retrospective, cohort study, we analysed SI levels in septic (n = 18) and nonseptic (n = 20) patients at 1 (baseline), 4, 8, 12, 16, 20, and 24 h of their Intensive Care Unit admission. Patients with diabetes mellitus Type I or Type II were excluded from the study. The SI levels were derived by fitting the blood glucose levels, insulin infusion and glucose input rates into the Intensive Control of insulin Nutrition Glucose model. Results: The median SI levels were significantly lower in the sepsis than in the nonsepsis at all follow up time points. The areas under the receiver operating characteristic curve of the model based SI at baseline for discriminating sepsis from nonsepsis was 0.814 (95% confidence interval, 0.675–0.953). The optimal cut-off point of the SI test was 1.573 × 10-4 L/mu/min. At this cut-off point, the sensitivity was 77.8%, specificity was 75%, positive predictive value was 73.7%, and negative predictive value was 78.9%. Conclusions: Model based SI ruled in and ruled out sepsis with fairly high sensitivity and specificity in our critically ill nondiabetic patients. These findings can be used as a foundation for further, prospective investigation in this area

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

Insulin sensitivity and blood glucose level of sepsis patients in the intensive care unit

Sepsis and hyperglycemia are highly associated with increases in mortality rates, particularly in the critically ill patients. Sepsis diagnosis has been proven challenging due to delay in getting the blood culture results. Thus, often clinical experiences overrule the protocol to prevent the worsening outcome of the patients. In some cases, the erroneous clinical judgement cause antibiotic resistance and even adverse clinical outcomes. This paper investigates the correlation between two parameters; insulin sensitivity and blood glucose level among sepsis patients. The blood glucose level is measured at the bedside during the patient's stay, whereas insulin sensitivity is obtained using the validated glucose-insulin model. Thus, the insulin sensitivity is a specific parameter of the patient, unregimented of the protocol given to the patient. The same parameters, blood glucose and insulin sensitivity, are also compared to the non-sepsis patients to establish a relationship that can be used for sepsis diagnosis. Given the availability of these two parameters that can be captured rapidly and instantly, a significant relationship can, therefore, help clinicians to identify sepsis at an early stage without second-guessing

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