Comparison of Prophylactic Phenylephrine Infusion and Rescue Bolus Administration for Maintaining Blood Pressure During Spinal Anaesthesia for Caesarean Delivery in Obese Parturient: A Randomised Control Trial.

Background: Phenylephrine (PE) is one of the vasopressor used to treat hypotension during anaesthesia. The primary aim of this study was to compare the effect of prophylactic infusion and rescue bolus of PE on the haemodynamic changes during spinal anaesthesia (SA) for Caesarean section (CS) in obese parturients. Methods: A total of 74 obese parturients scheduled for elective CS under SA were randomised into two groups; Group A (n = 37) received prophylactic PE infusion starting at 50 µg min-1 and adjusted according to the given algorithm and Group B (n = 37) received 100 µg PE bolus to treat hypotension. The measured parameters were systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), the total requirement of PE and neonatal Apgar score. Results: Six patients were excluded from the analysis due to missing data and only 68 were analysed. Group A showed significantly higher SBP, DBP and MAP than Group B (P < 0.05). The requirement of PE was higher in Group A than Group B [817.7 (265.7) µg versus 360.6 (156.0) µg; P = < 0.05]. Both groups had no difference in terms of the neonatal Apgar score. Conclusion: Prophylactic PE infusion provided better haemodynamic control than therapeutic boluses in obese parturients undergoing CS under SA.

Predictors of Treatment Failure and Mortality among Patients with Septic Shock Treated with Meropenem in the Intensive Care Unit.

Background: The aim of the study was to determine the predictors of meropenem treatment failure and mortality in the Intensive Care Unit (ICU). Methods: This was a retrospective study, involving sepsis and septic shock patients who were admitted to the ICU and received intravenous meropenem. Treatment failure is defined as evidence of non-resolved fever, non-reduced total white cell (TWC), non-reduced C-reactive protein (CRP), subsequent culture negative and death in ICU. Results: An Acute Physiology and Chronic Health Evaluation II (APACHE II) and duration of antibiotic treatment less than 5 days were associated with treatment failure with adjusted OR = 1.24 (95% CI: 1.15, 1.33; P < 0.001), OR = 65.43 (95% CI: 21.70, 197.23; P < 0.001). A higher risk of mortality was observed with higher APACHE and Sequential Organ Failure Assessment (SOFA) scores, initiating antibiotics > 72 h of sepsis, duration of antibiotic treatment less than 5 days and meropenem with renal adjustment dose with an adjusted OR = 1.21 (95% CI: 1.12, 1.30; P < 0.001), adjusted OR = 1.23 (95% CI: 1.08, 1.41; P < 0.001), adjusted OR = 6.38 (95% CI: 1.67, 24.50; P = 0.007), adjusted OR = 0.03 (95% CI: 0.01, 0.14; P < 0.001), adjusted OR = 0.30 (95% CI: 0.14, 0.64; P = 0.002). Conclusion: A total of 50 (14.12%) patients had a treatment failure with meropenem with 120 (48.02%) ICU mortality. The predictors of meropenem failure are higher APACHE score and shorter duration of meropenem treatment. The high APACHE, high SOFA score, initiating antibiotics more than 72 h of sepsis, shorter duration of treatment and meropenem with renal adjustment dose were predictors of mortality.

A case report: Community-acquired Pseudomonas aeruginosa necrotizing fasciitis in a morbidly obese diabetic young man can be fatal.

We present a case study of a 26-year-old morbidly obese man with a three-day history of right leg pain and swelling. The swelling was associated with low grade fever. He was alert and conscious upon presentation to the hospital. His physical examination showed gross swelling of the entire right lower limb with no systemic manifestations. There was no discharge and bullae from the swelling area of the leg. He had high blood sugar and was newly diagnosed with type 2 diabetes mellitus. He was diagnosed with necrotizing fasciitis. An intravenous imipenem-cilastatin 500 mg every 6 h together with clindamycin 900 mg every 8 h was started empirically. Extensive wound debridement was performed. The swab culture obtained intraoperatively grew Pseudomonas aeruginosa. He required an above knee amputation due to worsening infection despite wound debridement. Post-operatively, he developed acute kidney injury with severe metabolic acidosis, which required daily hemodialysis. However, the patient deteriorated due to septic shock with multi-organ failure, resulting in his death.

Undiagnosed chicken meat aspiration as a cause of difficult-to-ventilate in a boy with traumatic brain injury.

INTRODUCTION: Bronchoscopy is a commonly used procedure in the context of aspiration in the Intensive Care Unit setting. Despite its ability to remove mucus plug and undigested gastric contents, aspiration of gastric content into the trachea is one of the most feared complications among anesthesiologist. DISCUSSION: The scenario is made worst if the aspiration causes acute hypoxemic respiratory failure immediately post intubation. However, in the event of desaturation, the quick decision to proceed with bronchoscopy is a challenging task to the anesthesiologist without knowing the causes. CASE PRESENTATION: We present a case of a 12-year-old boy who had a difficult-to-ventilate scenario post transferring and immediately connected to ventilator in operation theatre (OT) from portable ventilator from the emergency department. She was successfully managed by bronchoscopy. CONCLUSION: Special attention should be given to the difficult-to-ventilate scenario post intubation of traumatic brain injury patient prior to operation. Prompt diagnosis and bronchoscope-assisted removal of foreign body was found to be a successful to reduce morbidity and mortality.

Factors that influence pain intensity and fentanyl requirements after a gynecologic laparotomy.

The association between pain intensity and its control by intravenous patient-controlled analgesia (IV-PCA) with fentanyl after a laparotomy for cystectomy/salphingoophorectomy, myomectomy, or hysterectomy was investigated. IV fentanyl infusion was administered to patients (n = 94) at 3 µg/kg/h to provide intraoperative analgesia after induction of general anesthesia. Postoperative fentanyl requirements were quantified via IV-PCA, and the amounts of rescue fentanyl required both during and after surgery were recorded. Mean values for PCA use as well as the visual analog scores (VAS) for pain were documented for up to 24 hours. The association between postoperative fentanyl requirements and VAS were then analyzed by using Mann-Whitney or Kruskal-Wallis tests. Patients with lower midline incisions had greater degrees of pain (p < .05) during the first 16 hours after surgery but did not consume more fentanyl compared with patients with Pfannenstiel incisions. Subjects who underwent operations lasting >4 hours required more rescue fentanyl during surgery (p < .05). However, this group consumed less fentanyl during the first 4 hours after surgery (p < .05). The demand at the fourth 4-hour period was lower among subjects undergoing myomectomy compared with cystectomy/salphingoophorectomy or hysterectomy (p = .045). Only a poor correlation was observed between pain intensity and analgesic usage. Postoperative pain intensity is influenced by the type of surgical incision but not the type of gynecologic surgery nor the duration of surgery. The relationship between subjective pain ratings with analgesic consumption is weak. Prolonged intraoperative administration of continuous IV fentanyl infusion may reduce fentanyl requirements in the immediate postoperative period.

Hand decontamination practices and the appropriate use of gloves in two adult intensive care units in Malaysia.

BACKGROUND: Hand decontamination is a critical infection control practice in the prevention of nosocomial infection. This study was conducted to observe the hand hygiene practices of nurses and doctors in two intensive care units (ICUs) in Malaysia. METHODOLOGY: Staff members were observed during patient contacts, and their hand washing techniques and hand hygiene practices were monitored. Five contact periods were observed for staff members while they cared for their assigned patients. Hand hygiene practices before and after patient contacts were categorized as clean uncontaminated, clean recontaminated, new gloves, and unchanged contaminated gloves. Compliance to hand-washing steps and time taken for hand washing were analyzed. Appropriate use of gloves based on CDC criteria also was assessed. RESULTS: Compliance to hand hygiene practices was 70% before each patient contact. Staff members did not completely adhere to the hand-washing steps. The average time taken to wash hands was 20 seconds, and the necessary steps (rubbing palm over dorsum; rubbing fingers interlaced, and rotational rubbing of thumbs) were practiced minimally by all staff. Hand washing protocol was generally followed by all staff (100%). Alcohol hand rubs were available but were used moderately (60%); when used, staff members did not wait for the alcohol to dry. Only 4% of staff changed contaminated gloves between patients. CONCLUSIONS: Hand hygiene compliance by ICU staff members needs to be improved. Improving adherence to correct hand hygiene techniques will require effective education programs and behavioral modification techniques. Moreover, hand hygiene guidelines must be incorporated into new staff orientation programs and the continuing education curriculum in the two hospitals studied.

Ventilator-associated nosocomial pneumonia in intensive care units in Malaysia.

BACKGROUND: The outcome indicator of nosocomial infection (NI) in the intensive care unit (ICU) is used to benchmark the quality of patient care in Malaysia. We conducted a three-year prospective study on the incidences of ventilator-associated pneumonia (VAP), risk factors, and patterns of the microorganisms isolated in three ICUs. METHODOLOGY: A follow-up in prospective cohort surveillance was conducted on patients admitted to an adult medical-surgical ICU of a university hospital and two governmental hospitals in Malaysia from October 2003 to December 2006. VAP was detected using CDC criteria which included clinical manifestation and confirmed endotracheal secretion culture results. RESULTS: In total, 215 patients (2,306 patient-days) were enrolled into the study. The incidence of ICU-acquired device-related NI was 29.3 % (n = 63). The device-related VAP infection rate was 27.0 % (n = 58), with a mechanical ventilator utilization rate of 88.7%. The death rate due to all ICU-acquired NI including sepsis was 6.5%. The most common causative pathogen was Klebsiella pneumoniae (n = 27). Multivariate analysis using Cox regression showed that the risk factors identified were aspiration pneumonia (HR = 4.09; 95% CI = 1.24, 13.51; P = 0.021), cancer (HR = 2.51; 95% CI = 1.27, 4.97; P = 0.008), leucocytosis (HR=3.43; 95% CI= 1.60, 7.37; P=0.002) and duration of mechanical ventilation (HR=1.04; 95% CI = 1.00, 1.08; P = 0.030). Age, gender and race were not identified as risk factors in the multivariable analysis performed. CONCLUSION: The incidence of VAP was comparable to that found in the National Nosocomial Infection Surveillance (NNIS) System report of June 1998. The incidence of VAP was considered high for the three hospitals studied.