Singapore SPICE: sedation practices in intensive care evaluation in Singapore - a prospective cohort study of the public healthcare system.

INTRODUCTION: A study was conducted to describe the sedation practices of intensive care units (ICUs) in Singapore in terms of drug use, sedation depth and the incidence of delirium in both early (< 48 hours) and late (> 48 hours) periods of ICU admission. METHODS: A prospective multicentre cohort study was conducted on patients who were expected to be sedated and ventilated for over 24 hours in seven ICUs (surgical ICU, n = 4; medical ICU, n = 3) of four major public hospitals in Singapore. Patients were followed up to 28 days or until ICU discharge, with four-hourly sedation monitoring and daily delirium assessment by trained nurses. The Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) were used. RESULTS: We enrolled 198 patients over a five-month period. The mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 25.3 ± 9.2, and 90.9% were emergency hospital admissions. Patients were followed up for 1,417 ICU patient days, of which 396 days were in the early period and 1,021 days were in the late period. 7,354 RASS assessments were performed. Propofol and fentanyl were the sedative agents of choice in the early and late periods, respectively. Patients were mostly in the light sedation range, especially in the late period. At least one episode of delirium was seen in 23.7% of patients. CONCLUSION: Sedation practices in Singapore ICUs are characterised by light sedation depth and low incidence of delirium, possibly due to the drugs used.

Factors Associated with Reintubation in an Intensive Care Unit: A Prospective Observational Study.

BACKGROUND AND AIMS: The objective of the study was to determine the incidence of failed extubations in our Intensive Care Unit (ICU) and identify associated clinical factors. MATERIALS AND METHODS: A prospective observational study of mechanically ventilated patients who underwent extubation attempts in our (predominantly surgical) ICU was undertaken from July 2012 to August 2013. The primary endpoint was the need for nonelective reintubation within 72 h of extubation. Clinical data of the reintubated patients were compared with those who were successfully extubated to identify factors associated with reintubation. RESULTS: Five hundred and eight extubation attempts were documented, 38 (7.5%) of which were unsuccessful. On multivariate analysis, the following clinical factors were found to be associated with an increased risk of failed extubation: unplanned extubations (adjusted odds ratio [OR] 5.8), the use of noninvasive ventilation (NIV) postextubation (adjusted OR 3.2), and sepsis (adjusted OR 2.9). Patient demographic factors, other premorbid and comorbid medical conditions, and differences of laboratory parameters did not appear to significantly influence reintubation rates in our study. CONCLUSIONS: Our study has demonstrated a relatively low reintubation rate, likely due to inclusion of elective admissions/intubations in our patient population. Unplanned extubations, the use of NIV postextubation, and sepsis were associated with increased reintubation risk, reinforcing the need for increased vigilance in this subgroup of patients after extubation.

Massaging the outcome: an unusual presentation of pulmonary embolism.

A 56-year-old man with a previous deep venous thrombus presented with dyspnoea after a leg massage. A transthoracic echocardiogram demonstrated a "worm-shaped" right atrial embolus, most probably a femoral cast. A pulmonary artery angiogram confirmed a large wedge-shaped perfusion defect caused by a pulmonary embolus. There are previous case reports about leg massage causing pulmonary emboli but this is the first reported event where the thrombus has been visualised directly. Also, it demonstrates the important role that echocardiography plays in pulmonary embolus.