Upper limb extravasation injury following remifentanil infusion at the limb covered with adhesive wrapping for hypothermia prevention during anesthesia of pediatric patient

We reported on a case involving a 41-day-old baby girl with a recurrent left supraglottic cyst and mild laryngomalacia who was scheduled for direct laryngoscopy and re-marsupialization. She sustained an extravasation injury following a remifentanil infusion during anesthesia, which was identified after the completion of surgery and the removal of surgical draping. The use of adhesive wrapping over the affected peripheral limbs to prevent hypothermia might have aggravated the ongoing extravasation injury. Immediate multidisciplinary management involving orthopedic and plastic reconstructive surgeries facilitated the smooth recovery of the patient. This case highlights the potential inadvertent complications that can arise intraoperatively during a continuous infusion of remifentanil in pediatric patients, as well as the aggravating factor of adhesive wrapping

Direct Brain Cooling in Treating Severe Traumatic Head Injury

There are scientific evidences that hypothermia provides a strong neuroprotective effect on the brain following traumatic insults. In this chapter, we describe the pathophysiology of severe head injury with emphasis on benefits of hypothermia. To support these hypothetical or theoretical benefits, we describe our previous study with very encouraging findings done on severe head injuries, treated with direct focal brain cooling, and monitored with intracranial pressure, cerebral perfusion pressure, brain oxygenation, and brain temperature. This chapter ends with our current and still ongoing study in which one of its main objectives is to innovate a direct focal brain cooling machine. This chapter briefly explains the technical part of this cooling machine

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

Comparison of Dexmedetomidine 50μg versus 100μg added to 0.5% Levobupivacaine in Supraclavicular Brachial Plexus Block (BPB) for Arteriovenous Fistula (AVF) Surgery

Background: Dexmedetomidine is an alpha-2 agonist used as sedation in ICU and remote anaesthesia. Unlike Clonidine, its effect as additive in peripheral nerve block has not been widely researched upon. The aim of this study is to compare the efficacy and outcome of additive dexmedetomidine 50μg versus 100μg to levobupivacaine 0.5% in supraclavicular brachial plexus block in AVF surgery . Methodology: Forty six adult with chronic renal failure patients scheduled for AVF surgery were studied in prospective, randomized, single operator double blinded study design. The supraclavicular block was performed with the ultrasound and a nerve stimulator technique.Group A (dexmedetomidine 50μg added to 20 ml of levobupivacaine 0.5 % + 1ml of normal saline) versus Group B (dexmedetomidine 100μg added to 20 ml of levobupivacaine 0.5 %). The onset, duration of action, haemodynamic parameters changes, vascular diameter changes and sedative effects were recorded Result: The onset of sensory and block is faster in Group B (8.08 ± 1.38); (P 0.5) Both group have a stable haemodynamic profiles. Group B causes significant increased the artery (0.020 ± 0.0067); (P<0.02) and vein diameter (0.022 ± 0.0074); (P<0.001). Conclusion: Dexmedetomidine as an additive for supraclacvicular block in ESRF patient for AVF surgery causes faster onset, prolonged duration of anesthesia, increase the artery and vein diameter and produced sedation effect with stable haemodynamic parameters

Case report: Unusual cause of difficulty in intubation and ventilation with asthmatic-like presentation of Endobronchial Tuberculosis

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

A comparative study of target controlled infusion (TCI) and manual controlled infusion (MCI) of propofol for sedation during cerebral protection in severe traumatic brain injured patient

Background. The aims of this study are to compare TCI with MCI propofol as sedation in severe traumatic brain-injured (TBI) patients. Methods. Post emergency craniotomy for severe mi patients (n = 50), were randomly assigned to receive propofol sedation over 24 hours using two modes of infusion: TCI versus MCI (n = 25 in each groups). Sedation was monitored using bispectral index SSIS) monitor and sedation agitation scale (SAS). TCI was titrated between 0.2-2.0 J.l.g mr and MCI was between 0.3-4.0 mg kg-1 h-1 to achieve sedative state at BIS 60-70 and SAS 2-3. Mean arterial pressure (MAP), heart rate (HR), intracranial pressure (ICP), cerebral perfusion pressure (CPP), time taken and volume used to achieve BIS 70, total volume of propofol over 24 hours and recovery time to BIS 90 were recorded. Results. TCI achieved BIS 70 significantly faster than MCI (6.3 ± 2.9 min vs. 19.7 ± 7.0 min). Total volume of propofol at BIS 70 was significantly less in TCI (12.0 ± 2.9 ml vs.17.8 ± 4.3 ml). Recovery time to BIS 90 was also significantly faster in TCI (24.4 ± 11.5 min vs. 57.3 ± 19.9 min). TCI showed significantly lower in HR and ICP trends over 24 hours. CPP trends were significantly higher in TCI. There were no significant differences in MAP and total volume over 24 hours. Conclusions. TCI modes had more advantages for propofol sedation in TBI by providing faster onset and offset of sedation and better in controlling ICP and CPP

The History of Awake Craniotomy in Hospital Universiti Sains Malaysia

Awake craniotomy is a brain surgery performed on awake patients and is indicated for certain intracranial pathologies. These include procedures that require an awake patient for electrocorticographic mapping or precise electrophysiological recordings, resection of lesions located close to or in the motor and speech of the brain, or minor intracranial procedures that aim to avoid general anaesthesia for faster recovery and earlier discharge. This type of brain surgery is quite new and has only recently begun to be performed in a few neurosurgical centres in Malaysia. The success of the surgery requires exceptional teamwork from the neurosurgeon, neuroanaesthesiologist, and neurologist. The aim of this article is to briefly describe the history of awake craniotomy procedures at our institution