A Comparison of the Effects of Prolonged Infusion of Propofol 2% and 1% During Total Intravenous Anaesthesia Using Target-Controlled Infusion Technique for Elective Neurosurgery.

Background: Total intravenous anaesthesia (TIVA) with a combination of target-controlled infusions (TCIs) of propofol and remifentanil has been advocated for a favourable neurosurgical outcome. Neurosurgical procedures often involve a prolonged duration and large cumulative infusion of propofol. This study compares the serial serum lipid profile, acid-base balance and lactate level of neurosurgical patients anaesthetised with TCIs of propofol at 2% versus 1%. Methods: A total of 74 patients who underwent an elective craniotomy under general anaesthesia were randomised into two groups: i) propofol 1% (n = 37) and ii) propofol 2% (n = 37). All patients were anaesthetised using TCIs of propofol and remifentanil. Serial lipid profiles (serum triglyceride [TG] and cholesterol levels) were taken at the baseline, upon cessation of propofol and at 2 h post-operation. The total dosage, volume used and syringe changes of both groups were also documented. Results: The total volume of propofol used was significantly lower in the 2% group than the 1% group (157.19 mL [SD = 77.14] versus 335.17 mL [SD = 174.27]; P = 0.005) and the frequency of syringe changes was also less in the 2% than the 1% group (2 [3] versus 6 [3]; P < 0.001). However, there were no significant differences between the two groups in terms of serial serum TG, cholesterol, the acid-base balance or the lactate level. There was also no significant correlation of lipid profile with cumulative dose or volume of propofol infused between the two groups. Conclusion: Both concentrations of propofol, 1% and 2%, were comparable in terms of the serial lipid profile, acid-base balance and lactate level during TIVA using TCIs for elective neurosurgery. The benefits of propofol at 2% were that a lower volume was used and there were fewer syringe changes, which could minimise anaesthesia interruption throughout surgery.

The Practice, Outcome and Complications of Tracheostomy in Traumatic Brain Injury Patients in a Neurosurgical Intensive Care Unit: Surgical versus Percutaneous Tracheostomy and Early versus Late Tracheostomy.

Background: The tracheostomy procedure is commonly required to wean patients off the severe traumatic brain injury (TBI). This study aimed to determine the practice, outcome and complications of two techniques: i) surgical tracheostomy (ST) versus percutaneous tracheostomy (PT) and ii) two different times of procedure: early tracheostomy (ET) versus late tracheostomy (LT). Methods: This was a retrospective, cross-sectional study conducted from 1 January 2013 until 31 December 2017, involving 268 severe TBI patients who required tracheostomy during neurosurgical intensive care unit (Neuro-ICU) management. The data were obtained from their medical records. Results: When based on techniques, PT displayed a significantly shorter day of tracheostomy plan (7.0 [2.5] versus 8.3 [2.6] days; P < 0.001); day of execution (7.2 [2.6] versus 8.6 [2.9] days; P < 0.001); duration of mechanical ventilation (9.8 [3.4] versus 11.3 [3.1] days; P < 0.001) and duration of ICU stay (12.3 [3.7] versus 13.8 [3.5] days; P < 0.003) than ST. If based on timing, ET showed a significantly shorter duration of mechanical ventilation (8.8 [2.1] versus 12.9 [2.9] days; P < 0.001), length of ICU stay (11.4 [2.4] versus 15.2 [3.5] days; P < 0.001) and length of hospital stay (17.1 [3.2] versus 20.0 [4.0] days; P < 0.001) than LT. Conclusion: PT showed a shorter mechanical ventilation and ICU stay duration than ST. In comparison, ET showed shorter mechanical ventilation, ICU stay and hospital stay duration than LT.

Comparison of the Parker flex tip and the unoflex reinforced endotracheal tube for orotracheal fibreoptic intubation in simulated difficult intubation patients.

INTRODUCTION: The choice of endotracheal tube (ETT) is important for successful orotracheal fibreoptic intubation (OFI). The aim of this study was to compare the use of the Parker flex tip (PFT) with the unoflex reinforced (UFR) ETT during OFI. MATERIAL AND METHODS: A total of 58 patients who underwent elective surgery under general anaesthesia were randomised to two ETT groups, the PFT group (n = 29) and the UFR group (n = 29), for OFI in simulated difficult intubation patients using a rigid cervical collar. After successful standardised induction and relaxation, OFI and railroading of selected ETT were subsequently performed by a similarly experienced practitioner. Ease of insertion, degree of manipulation, time to successful intubation, post-intubation complications and haemodynamic changes were recorded for both groups. RESULTS: he percentage of easy intubation was comparable between both groups with a slightly higher percentage in the UFR group than the PFT group (69.0% vs. 62.0%; P = 0.599). Degree of manipulation was also comparable between the two groups; the percentage of cases in which manipulation was not required was slightly higher in the UFR group than the PFT group (69.0% vs. 62.1%; P = 0.849). Time to successful intubation was also comparable between the groups, although the time was slightly shorter for the UFR group than the PFT group (56.9 s ± 39.7 s vs. 63.9 s ± 36.9 s; P = 0.488). There were also no significant differences in other parameters. CONCLUSIONS: The Parker flex tip ETT was comparable to the unoflex reinforced ETT for OFI in simulated difficult airway patients.

Comparing the Effects of Pre-loading with Gelatine 4% Plasma Volume Expander and 6% Hydroxyethyl Starch Solution Before Spinal Anaesthesia for Lower Limb Orthopaedic Surgery.

BACKGROUND: Hypotension is a common complication following spinal anaesthesia. The administration of intravenous fluids prior to spinal anaesthesia, known as pre-loading, has been used to offset the hypotension effect; however, the ideal fluid for pre-loading is still a matter of debate. The objective of this study was to compare the effects of Gelaspan 4% and Volulyte 6% as pre-loading fluids. METHODS: A total of 93 patients with American Society of Anaesthesiologists (ASA) physical status I or II having lower limb orthopaedic surgery under spinal anaesthesia were randomised into two groups that received either Volulyte (n = 47) or Gelaspan (n = 46). Before the spinal anaesthesia, these patients were pre-loaded with 500 mL of the fluid of their respective group. Blood samples were taken before pre-loading and again after spinal anaesthesia and sent for venous blood gas and electrolyte level measurement. Baseline and intraoperative records of systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR) and the requirement of ephedrine to treat hypotension were also recorded. RESULTS: Both fluids could not prevent significant reductions in SBP (P = 0.011), DBP (P = 0.002) and MAP (P = 0.001). There was also significant reduction in HR over time (P < 0.001). There was no significant difference in terms of ephedrine usage between both groups. Neither Volulyte 6% nor Gelaspan 4% caused significant changes in acid-base status. CONCLUSION: The use of 500 mL of either Gelaspan 4% or Volulyte 6% as pre-loading fluids did not significantly prevent the incidence of post-spinal anaesthesia hypotension following orthopaedic lower limb surgery; however, both were useful in the maintenance normal acid-base balance.

Sugammadex Rescue in Avoiding Intensive Care Unit Admission in an Octogenarian Undergoing Emergency Laparotomy.

Postlaparotomy management for elderly patients with underlying comorbidities is always a challenge because of poor cardiorespiratory reserves and prolonged effect of anesthetic drugs. For these reasons, such patients usually require intensive care unit (ICU) admission in the postoperative period. We report a case of an 85-year-old chronic smoker with controlled diabetes mellitus who needed an emergency laparotomy for a perforated gastric ulcer. Unfortunately, there was a shortage of ICU backup. With the successful conduct of an early surgery using combined general and regional anesthesia, the use of sugammadex (Bridion, Merck Sharp & Dohme Corp, Oss, the Netherlands) as a reversal agent, a skilled surgeon, and good postanesthesia care, the patient did not require ICU admission. He recovered fast and was discharged home 4 days after surgery. This case study aims to contribute to the literature on experience of a successful conduct of anesthesia in a high-risk geriatric patient when ICU facilities are limited.

The dangers of accepting a single diagnosis: case report of concurrent Plasmodium knowlesi malaria and dengue infection.

BACKGROUND: Dengue and malaria are two common, mosquito-borne infections, which may lead to mortality if not managed properly. Concurrent infections of dengue and malaria are rare due to the different habitats of its vectors and activities of different carrier mosquitoes. The first case reported was in 2005. Since then, several concurrent infections have been reported between the dengue virus (DENV) and the malaria protozoans, Plasmodium falciparum and Plasmodium vivax. Symptoms of each infection may be masked by a simultaneous second infection, resulting in late treatment and severe complications. Plasmodium knowlesi is also a common cause of malaria in Malaysia with one of the highest rates of mortality. This report is one of the earliest in literature of concomitant infection between DENV and P. knowlesi in which a delay in diagnosis had placed a patient in a life-threatening situation. CASE PRESENTATION: A 59-year old man staying near the Belum-Temengor rainforest at the Malaysia-Thailand border was admitted with fever for 6 days, with respiratory distress. His non-structural protein 1 antigen and Anti-DENV Immunoglobulin M tests were positive. He was treated for severe dengue with compensated shock. Treating the dengue had so distracted the clinicians that a blood film for the malaria parasite was not done. Despite aggressive supportive treatment in the intensive care unit (ICU), the patient had unresolved acidosis as well as multi-organ failure involving respiratory, renal, liver, and haematological systems. It was due to the presentation of shivering in the ICU, that a blood film was done on the second day that revealed the presence of P. knowlesi with a parasite count of 520,000/µL. The patient was subsequently treated with artesunate-doxycycline and made a good recovery after nine days in ICU. CONCLUSIONS: This case contributes to the body of literature on co-infection between DENV and P. knowlesi and highlights the clinical consequences, which can be severe. Awareness should be raised among health-care workers on the possibility of dengue-malaria co-infection in this region. Further research is required to determine the real incidence and risk of co-infection in order to improve the management of acute febrile illness.