The Effectiveness of Dedicated Trauma Operation Theatre and Trauma Intensive Care Unit on the Outcomes of Patients with Traumatic Brain Injury after Emergency Neurosurgery.

Background: A dedicated trauma operation theatre (TOT) and a trauma intensive care unit (TICU) within the same block as the emergency department (ED) can facilitate immediate management and surgery of patients suffering from traumatic brain injury (TBI). The present study compared the effectiveness and outcomes of TBI management between the TOT-TICU and general OT (GOT) and neuro-ICU (NICU) setups. Methods: This was a retrospective cohort study involving 120 patients with TBI who were divided into the GOT-NICU (n = 63) and TOT-TICU (n = 57) groups. Data were obtained from patients' admission and medical records. Demographic data, durations of specific management phases and outcomes of patients were documented. Results: In the TOT-TICU group, the duration of transportation from ED to OT [15 (standard deviation [SD] = 15) min versus 45 (SD = 15) min; P < 0.001], duration of arrival in OT to incision [50 (SD = 30) versus 70 (SD = 23) min; P = 0.005] and duration of transportation from OT to ICU [40 (SD = 17) versus 48 (SD = 30); P = 0.005] were significantly shorter than those in the GOT-NICU group. However, the duration of mechanical ventilation, duration of ICU stays, Glasgow Outcome Scale (GOS) upon discharge and GOS at 3-month post-discharge were comparable between both groups. Conclusion: The TOT-TICU setup shortened the duration of transportation from ED to OT, duration of arrival in OT to incision and duration of transportation from OT to ICU compared with the GOT-NICU setup. Hence, the availability of OT and ICU within the trauma block managed to provide immediate management to TBI patients.

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. How to cite this article: Lim KY, Shukeri WFWM, Hassan WMNW, Mat-Nor MB, Hanafi MH. The Combined Use of Interleukin-6 with Serum Albumin for Mortality Prediction in Critically Ill Elderly Patients: The Interleukin-6-to-albumin Ratio. Indian J Crit Care Med 2022;26(10):1126-1130.

Comparison of Combination Between Ketamine and Parecoxib as Multimodal Preemptive Analgesia With Ketamine Alone for Elective Laparotomy.

BACKGROUND: Preemptive analgesia is important for reducing postoperative analgesia requirement. Therefore, this study compared the efficacy of intravenous (IV) ketamine alone with the efficacy of a combination of low-dose IV ketamine and IV parecoxib as part of a multimodal preemptive analgesia regimen in patients undergoing elective laparotomy. METHODS: In this prospective study, 48 patients scheduled for elective laparotomy were randomized to two groups of preemptive analgesia, namely, group K-P, in which anestheologists administered a combination of 0.3 mg/kg IV ketamine and 40.0 mg IV parecoxib, or group K, in which ones gave 0.3 mg/kg IV ketamine alone. Patients from both groups underwent surgery under general anesthesia, and total intraoperative opioid requirement was recorded. After surgery, morphine administered by automated patient-controlled analgesia (PCA) infusion device was initiated in all patients. Pain score was assessed using the visual analogue scale (VAS), and postoperative opioid requirement was recorded at 1 and 4 hours, and subsequently from 4-hour intervals up to 24 hours after surgery. RESULTS: Compared to group K, group K-P required significantly lower rescue IV fentanyl in the recovery bay (0.10 ± 0.28 vs. 0.35 ± 0.46 µg/kg; P = 0.031), showing prolonged time-to-first analgesic request recorded by PCA device (70.8 ± 40.0 vs. 22.2 ± 15.8 mins; P ＜ 0.001), lower total morphine requirement delivered by PCA device (8.0 ± 4.6 vs. 16.8 ± 6.5 mg; P ＜ 0.001), and lower VAS values measured at all time points. There was no significant difference in intraoperative total opioid requirement between the groups. CONCLUSIONS: Among laparotomy patients, multimodal preemptive analgesia by the use of a combination of low-dose IV ketamine and IV parecoxib was more effective than IV ketamine alone in reducing pain scores and postoperative analgesia requirement (e.g., PCA-administered morphine).

COVID-19 Pandemic and Its Impact on Neurosurgery Practice in Malaysia: Academic Insights, Clinical Experience and Protocols from March till August 2020.

The newly discovered coronavirus disease 2019 (COVID-19) is an infectious disease introduced to humans for the first time. Following the pandemic of COVID-19, there is a major shift of practices among surgical departments in response to an unprecedented surge in reducing the transmission of disease. With pooling and outsourcing of more health care workers to emergency rooms, public health care services and medical services, further in-hospital resources are prioritised to those in need. It is imperative to balance the requirements of caring for COVID-19 patients with imminent risk of delay to others who need care. As Malaysia now approaches the recovery phase following the pandemic, the crisis impacted significantly on neurosurgical services throughout the country. Various emergency measures taken at the height of the crisis may remain as the new normal in the provision of neurosurgical services and practices in Malaysia. The crisis has certainly put a strain on the effective delivery of services and as we approach the recovery era, what may have been a strain may prove to be a silver lining in neurosurgical services in Malaysia. The following details are various measures put in place as the new operational protocols for neurosurgical services in Malaysia.

Anastomotic Leak after Bariatric Surgery from a Critical Care Perspective: A Lesson Shared.

Anastomotic leak after bariatric surgery is a rare complication with a recent prevalence ranging from 0.8% to 1.5%. The complication nevertheless can result in morbidity and even mortality. The purpose of this paper is to present a patient who suffered from an anastomotic leak presenting 2 days after laparoscopic sleeve gastrectomy in our intensive care unit. Review of the current literature regarding this complication from critical care perspective is also attempted.

Deep Brain Stimulation (DBS) for Movement Disorders: An Experience in Hospital Universiti Sains Malaysia (HUSM) Involving 12 Patients.

Deep brain stimulation (DBS) was first introduced in 1987 to the developed world. As a developing country Malaysia begun its movement disorder program by doing ablation therapy using the Radionics system. Hospital Universiti Sains Malaysia a rural based teaching hospital had to take into consideration both health economics and outcomes in the area that it was providing neurosurgical care for when it initiated its Deep Brain Stimulation program. Most of the patients were from the low to medium social economic groups and could not afford payment for a DBS implant. We concentrated our DBS services to Parkinson's disease, Tourette's Syndrome and dystonia patients who had exhausted medical therapy. The case series of these patients and their follow-up are presented in this brief communication.

Life-Threatening Dyskalaemia after Barbiturate Coma Therapy: The Strategy of Management.

Barbiturate coma therapy (BCT) is a treatment option that is used for refractory intracranial hypertension after all other options have been exhausted. Although BCT is a brain protection treatment, it also has several side effects such as hypotension, hepatic dysfunction, renal dysfunction, respiratory complications and electrolyte imbalances. One less concerning but potentially life-threatening complication of BCT is dyskalaemia. This complication could present as severe refractory hypokalaemia during the therapy with subsequent rebound hyperkalaemia after cessation of the therapy. Judicious potassium replacement during severe refractory hypokalaemia and gradual cessation of the therapy to prevent rebound hyperkalaemia are recommended strategies to deal with this complication, based on previous case series and reports. In this case report, we show that these strategies were applicable in improving severe hypokalaemia and preventing sudden, life-threatening rebound hyperkalaemia. However, even with use of these strategies, BCT patients could still present with mild, asymptomatic hyperkalaemia.

Comparison of Single-Shot Intrathecal Morphine Injection and Continuous Epidural Bupivacaine for Post-Operative Analgaesia after Elective Abdominal Hysterectomy.

BACKGROUND: Abdominal hysterectomy (AH) is painful. The aim of this study was to compare intrathecal morphine (ITM) and epidural bupivacaine (EB) for their analgaesia effectiveness after this surgery. METHODS: Thirty-two patients undergoing elective AH were randomised into Group ITM (ITM 0.2 mg + 2.5 mL 0.5% bupivacaine) (n = 16) and Group EB (0.25% bupivacaine bolus + continuous infusion of 0.1% bupivacaine-fentanyl 2 µg/mL) (n = 16).The procedure was performed before induction, and all patients subsequently received standard general anaesthesia. Both groups were provided patient-controlled analgaesia morphine (PCAM) as a backup. Visual analogue scale (VAS) scores, total morphine consumption, hospital stay duration, early mobilisation time and first PCAM demand time were recorded. RESULTS: The median VAS score was lower for ITM than for EB after the 1st hour [1.0 (IqR 1.0) versus 3.0 (IqR 3.0), P < 0.001], 8th hour [1.0 (IqR 1.0) versus 2.0 (IqR 1.0), P = 0.018] and 16th hour [1.0 (IqR1.0) versus (1.0 (IqR 1.0), P = 0.006]. The mean VAS score at the 4th hour was also lower for ITM [1.8 (SD 1.2) versus 2.9 (SD 1.4), P = 0.027]. Total morphine consumption [11.3 (SD 6.6) versus 16.5 (SD 4.8) mg, P = 0.016] and early mobilisation time [2.1 (SD 0.3) versus 2.6 (SD 0.9) days, P = 0.025] were also less for ITM. No significant differences were noted for other assessments. CONCLUSIONS: The VAS score was better for ITM than for EB at earlier hours after surgery. However, in terms of acceptable analgaesia (VAS ≤ 3), both techniques were comparable over 24 hours.

Epilepsy Surgery in Hospital Universiti Sains Malaysia: Our Experiences since 2004.

Epilepsy surgery has been performed by a few centres in Malaysia, including Hospital Universiti Sains Malaysia (HUSM). To date, a total of 15 patients have undergone epilepsy surgery in HUSM. The epilepsy surgery included anterior temporal lobectomy (ATL) with amygdalohippocampectomy (AH) and Vagal nerve stimulation (VNS). The surgical outcomes of the patients were assessed using the International League Against Epilepsy (ILAE) outcome scale. The ILAE scores for patients who underwent ATL with AH were comparatively better than those who underwent VNS. One of the patient who underwent ATL with AH and frontal lesionectomy was found to have psychosis during follow up. Epilepsy surgery has proven to be an important treatment for medically resistant epilepsy. Thus it is important to raise public awareness regarding epilepsy and its treatment.

Target-controlled Infusion Propofol Versus Sevoflurane Anaesthesia for Emergency Traumatic Brain Surgery: Comparison of the Outcomes.

BACKGROUND: The choice of anaesthetic techniques is important for the outcome of traumatic brain injury (TBI) emergency surgery. The objective of this study was to compare patient outcomes for target-controlled infusion (TCI) of propofol and sevoflurane anaesthesia. METHODS: A total of 110 severe TBI patients, aged 18-60, who underwent emergency brain surgery were randomised into Group T (TCI) (n = 55) and Group S (sevoflurane) (n = 55). Anaesthesia was maintained in Group T with propofol target plasma concentration of 3-6 µg/mL and in Group S with minimum alveolar concentration (MAC) of sevoflurane 1.0-1.5. Both groups received TCI remifentanil 2-8 ng/mL for analgesia. After the surgery, patients were managed in the intensive care unit and were followed up until discharge for the outcome parameters. RESULTS: Demographic characteristics were comparable in both groups. Differences in Glasgow Outcome Scale (GOS) score at discharge were not significant between Group T and Group S (P = 0.25): the percentages of mortality (GOS 1) [27.3% versus 16.4%], vegetative and severe disability (GOS 2-3) [29.1% versus 41.8%] and good outcome (GOS 4-5) [43.6% versus 41.8%] were comparable in both groups. There were no significant differences in other outcome parameters. CONCLUSION: TCI propofol and sevoflurane anaesthesia were comparable in the outcomes of TBI patients after emergency surgery.

Balanced Fluid Versus Saline-Based Fluid in Post-operative Severe Traumatic Brain Injury Patients: Acid-Base and Electrolytes Assessment.

BACKGROUND: Normal saline (NS) is a common fluid of choice in neurosurgery and neuro-intensive care unit (ICU), but it does not contain other electrolytes and has the potential to cause hyperchloremic metabolic acidosis with prolonged infusion. These problems may be reduced with the availability of balanced fluid (BF), which becomes a more physiological isotonic solution with the presence of complete electrolyte content. This study aimed to compare the changes in electrolytes and acid-base between NS and BF (Sterofundin® ISO) therapy for post-operative severe traumatic brain injury (TBI) patients in neuro-ICU. METHODS: Sixty-six severe TBI patients who required emergency craniotomy or craniectomy and were planned for post-operative ventilation were randomised into NS (n = 33) and BF therapy groups (n = 33). The calculation of maintenance fluid given was based on the Holliday-Segar method. The electrolytes and acid-base parameters were assessed at an 8 h interval for 24 h. The data were analysed using repeated measures ANOVA. RESULTS: The NS group showed a significant lower base excess (-3.20 versus -1.35, P = 0.049), lower bicarbonate level (22.03 versus 23.48 mmol/L, P = 0.031), and more hyperchloremia (115.12 versus 111.74 mmol/L, P < 0.001) and hypokalemia (3.36 versus 3.70 mmol/L, P < 0.001) than the BF group at 24 h of therapy. The BF group showed a significantly higher level of calcium (1.97 versus 1.79 mmol/L, P = 0.003) and magnesium (0.94 versus 0.80 mmol/L, P < 0.001) than the NS group at 24 h of fluid therapy. No significant differences were found in pH, pCO2, lactate, and sodium level. CONCLUSION: BF therapy showed better effects in maintaining higher electrolyte parameters and reducing the trend toward hyperchloremic metabolic acidosis than the NS therapy during prolonged fluid therapy for postoperative TBI patients.

A rare complication of tracheal intubation.

Accidental endobronchial intubation is a frequent complication in critically ill patients requiring tracheal intubation (TI). If such complication occurs, it is more often the right main bronchus that is intubated due to anatomical reasons. Left main bronchus (LMB) intubation is rare. Here, we report a case with auscultatory, bronchoscopic, and radiographic evidence of accidental LMB intubation in a pregnant woman with dengue shock syndrome. We highlight this case to increase awareness about this possible-but-rare complication of TI.