A randomized controlled trial comparing minichest tube and needle aspiration in outpatient management of primary spontaneous pneumothorax.

OBJECTIVES: The aim of this study was to compare outcomes and complications associated with needle aspiration (NA) and minichest tube (MCT) insertion with Heimlich valve attachment in the treatment of primary spontaneous pneumothorax at an emergency department (ED). METHODS: Patients presenting with primary spontaneous pneumothorax were randomized to NA or MCT. They had repeat chest x-rays immediately after the procedure and 6 hours later. Patients who underwent NA were discharged if repeat x-rays showed less than 10% pneumothorax. Those who had MCT were discharged if repeat x-rays did not show worsening of pneumothorax. They were reviewed at the outpatient clinic within 3 days. The primary outcomes of interest were failure rate and admission rate. The secondary outcomes were complication rate, pain and satisfaction scores, length of hospital stay, and rate of full recovery during outpatient follow-up. RESULTS: There were 48 patients whose mean age was 25 years. We found no difference in failure rate between the groups, except that there were more MCT (24%) than NA patients (4%) with complete expansion at first review (difference, -0.20; 95% confidence interval, -0.38 to -0.01). Thirty-five percent of NA group and 20% of MCT group needed another procedure at the ED. Fifty-two percent of NA patients and 28% of MCT patients were admitted from the ED to the inpatient ward. Nine percent and 12%, respectively, of patients who had NA and MCT were admitted from the review clinic. Both groups of patients had equivalent pain scores, satisfaction scores, and complication rates. CONCLUSION: Both MCT and NA allowed safe management of primary spontaneous pneumothorax in the outpatient setting.

The oxygen delivery debate--a review.

Tissue hypoxia is an important cause for the development of multisystem organ failure in the critically ill. Achieving adequate haemodynamic support of oxygen demand is the mainstay of treatment in these patients. Controversies regarding therapeutic end-points do exist but in general maintaining oxygen delivery by ensuring adequate cardiac output, oxygen saturation and haemoglobin is important in the critically ill.

Tetanus in Singapore: report of three cases.

Three cases of tetanus in Singapore are presented. One local resident had cephalic tetanus most likely secondary to otitis media and the other two, residents from surrounding Asean countries, had generalised tetanus. The portal of entry was a puncture wound on the foot in one patient and the ear in another. No portal of entry was identified in one patient. All three patients required tracheostomy, ventilatory support and intensive care management for periods ranging from 11 to 22 days. One patient died from complications of nosocomial septicaemia and one patient required prolonged rehabilitation. There was a questionable history of tetanus immunization in the Singapore resident whereas the other two patients who were foreigners had never received any immunization. Tetanus is an uncommon but important disease in Singapore. In spite of the availability of intensive care management, it continues to be a disease with significant morbidity and mortality. Early recognition and treatment of the disease are critical factors in determining the prognosis. This is a disease that may be largely prevented by adequate immunization.

Influenza A H1N1 (2009): clinical spectrum of disease among adult patients admitted to a regional hospital in Singapore.

INTRODUCTION: The worldwide spread of Influenza A H1N1 (2009) has proceeded at an unprecedented rate, with the World Health Organization rapidly raising its influenza pandemic alert to phase six. We describe the disease spectrum of H1N1 (2009) to aid the triaging and identification of patients at risk. METHODS: This is a retrospective chart review of all confirmed H1N1 (2009) cases admitted to our institution between June and September 2009. RESULTS: The disease severity of the 153 patients studied was classified as mild (n is 75), moderate (n is 55) and severe (n is 23). 81 patients were female. The median age was 26 years. While comorbidities were more prevalent among patients with moderate-severe illness, 47.4 percent reported no pre-existing illness. Presenting complaints of breathlessness, tachycardia, low-pulse oximetry, higher leukocyte counts and C-reactive protein with low albumin levels were more commonly noted in moderate-severe illness (p-value less than 0.001). All patients received oseltamivir at a median of four days from illness onset. 18 required intensive care unit admission, with the majority (94.4 percent) within the first 24 hours of hospitalisation. The overall mortality rate was 4.6 percent. Median lengths of hospitalisation were four and nine days for moderate and severe cases, respectively. CONCLUSION: While the majority of H1N1 (2009) patients have mild illness, a subgroup can become critically ill. Prior good health is not necessarily a good discriminator against severe illness. The presence of dyspnoea, tachycardia and desaturation at triage should heighten the index of suspicion for H1N1 (2009)-related complications.

Severe refractory hypoxaemia in H1N1 (2009) intensive care patients: initial experience in an Asian regional hospital.

INTRODUCTION: The management of Influenza A (H1N1) patients with acute respiratory distress syndrome (ARDS) is an emerging challenge, especially during the 2009 pandemic. These patients frequently require advanced mechanical ventilation (MV) and on occasion, rescue therapy. We describe the demographics, presentation, course and outcomes of the first 12 H1N1 patients with ARDS who were admitted to our institution. METHODS: This was a retrospective chart review of H1N1 patients with ARDS who were admitted to our intensive care unit (ICU) between July and September 2009. RESULTS: Seven of the 12 patients were female. The median age was 46 (range 27-66) years. 25 percent of the patients had good health prior to the infection. The presenting symptoms were mainly cough (100 percent), fever (92 percent) and dyspnoea (64 percent). The median times from symptom onset to both hospitalisation and ICU admission were five (range 2-9) days. Ten (83 percent) patients required invasive MV within 24 hours of presentation. The mean PaO2/ FiO2 ratio was 87.9 +/- 37.3 mmHg, with a mean positive end expiratory pressure at 16.1 +/- 7.3 cm H2O. Three patients required either unconventional MV and/or prone positioning, inhaled nitric oxide or nebulised prostacyclin. The mean Acute Physiology and Chronic Health Evaluation II score was 12.7 +/- 9.1. Among survivors, the median number of ventilator days was 7.5 (range 5-11), with a median length of ICU stay of ten (range 6-14) days. The median length of hospitalisation was 13.5 (range 9-31) days. The mortality rate in our case series was 50 percent. CONCLUSION: Unlike patients of seasonal influenza, our severe H1N1 patients were of a younger age. A significant proportion had no underlying risk factors. Despite high ventilatory requirements, unconventional MV and adjunct therapy, the mortality rate remained high.

A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions.

OBJECTIVE: Differing success rates of various pleurodesis agents have been reported in the management of malignant pleural effusions. A randomized clinical trial was conducted to compare the efficacy of two commonly used agents, talc and bleomycin, for the pleurodesis of malignant pleural effusions. METHODOLOGY: Inclusion in the study required proof of a malignant pleural effusion by fluid cytology or pleural biopsy. Exclusion criteria included trapped lung, loculated effusions, recurrent effusions and life expectancy < 1 month. Five grams of talc or 1 unit per kilogram bodyweight of bleomycin mixed in 150 mL of normal saline was administered via tube thoracostomy after complete drainage of the pleural effusion in each patient. Treatment success was defined as the absence of recurrent pleural effusion on the chest radiograph 1 month after pleurodesis. RESULTS: Treatment success was achieved in 16 out of 18 patients (89%) in the talc slurry group versus 14 out of 20 patients (70%) in the bleomycin group (P=0.168). Fever and pain were the only side-effects of pleurodesis in both groups. CONCLUSION: These results indicate that talc slurry is as effective as bleomycin in preventing early recurrence of malignant pleural effusions. Pleurodesis with talc instead of bleomycin can result in significant cost savings.

MARS therapy in critically ill patients with advanced malignancy: a clinical and technical report.

BACKGROUND/METHODS: Molecular Adsorbent Recirculating System (MARS) was used in three consecutive critically ill patients at the Singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant Staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. MARS was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in Budd-Chiari syndrome. The latter precipitated ALF. MARS was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis B flare. He was given a trial of MARS once in the ICU. All the three patients eventually died. RESULTS: Mean MARS intradialytic systemic pressures were as follows: systolic pressure range was 95 +/- 17 to 128 +/- 17 mmHg and diastolic pressure range was 51 +/- 5 to 67 +/- 7 mmHg. Pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 +/- 11 to 339 +/- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 +/- 11 to 210 +/- 6 mmHg. Ultrafiltration (UF) was 633 +/- 622 mL over mean treatment duration of 6.3 +/- 0.9 h with a total heparin dose of 1583 +/- 817 IU. Coagulation status pre- and 6-h post-MARS was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. MARS had a significant de-uraemization effect (pre- and post-MARS serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of MARS. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous MARS operation. CONCLUSIONS: MARS was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise MARS circuit integrity. Although MARS had a significant de-uraemization effect, this appeared to be limited by the duration of MARS operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of MARS for different toxins that accumulate in ALF. This would affect the optimal duration of MARS therapy.