Point-of-Care Procalcitonin to Guide the Discontinuation of Antibiotic Treatment in the Intensive Care Unit: A Malaysian Randomised Controlled Trial

@#Introduction: This work aims to establish the practicality of simple point-of-care (POC) measurements of procalcitonin (PCT) coupled with the standard PCT-guided antibiotic treatment discontinuation algorithm to guide the cessation of antibiotic treatment in intensive care unit (ICU). Methods: In this randomised-controlled trial, 80 adult patients with suspected bacterial infections were randomised to either the POC PCT-guided arm (n = 40) or the standard-of-care arm (n = 40). The decision to discontinue antibiotic treatment in the POC PCT-guided arm was based on the POC PCT-guided antibiotic-treatment discontinuation strategy, which states that discontinuation is urged once the PCT concentration has reduced by ≥ 80% or to < 0.5 ng/mL. In the standard-of-care arm, the antibiotic-treatment duration followed the local guidelines. Results: The median duration of antibiotic treatment was 6.5 [IQR = 5.0-7.0] days in the POC PCT-guided antibiotic-treatment arm versus 7.5 [IQR = 5.0-14.0] days in the standard-of-care arm (p = 0.010). The mean antibiotic-free days in the first 30 days after study inclusion was 20.7 (SD = 5.3) days in the POC PCT-guided antibiotic-treatment arm versus 16.4 (SD = 7.4) days in the standard-of-care arm (p = 0.004). The number of patients who took an antibiotic for more than 10 days was 2 (5%) in the POC PCT-guided antibiotic-treatment arm versus 13 (32.5%) in the standard-of-care arm (p = 0.002). Conclusion: Antibiotic use in patients with symptoms of bacterial infections in the ICU was substantially minimised with the installation of a POC PCT-guided antibiotic-treatment cessation.

The Technique of Intravenous Ketamine Infusion on PostOperative Hyperalgesia in Gluteal Sarcoma

@#Post-Operative Hyperalgesia (POH) is an uncommon painful condition suffered after surgery. It is poorly identified and usually needs a large dose of strong opioids administration to attenuate pain. Primarily POH originated from the activation of N-Methyl-DE Aspartate Receptor (NMDAR) located at the spinal cord. Hence NMDAR antagonist (ketamine) may inhibit this pain mechanism leading to desirable post-operative pain relief. We presented a case report on how to recognize POH, initiated ketamine infusion, and its limitation. We found ketamine therapy reduced opioid requirements and drastically improve patient daily bed activities.

Effect of Single Dose Pre-induction Dexmedetomidine on Anaesthetic Requirement and Pain Profile in Orthopaedic Surgery: A Placebo-controlled Double Blind Randomised Controlled Trial

@#Introduction: Dexmedetomidine, a selective α2 -adrenoreceptor agonist is an important adjuvant to general anaesthetic practice in view of its potent sedative, anaesthetic-sparing and analgesic effects. We investigated the effect of a single dose pre – induction dexmedetomidine on the anaesthetic requirement during surgery and pain profile. Methods: 60 patients who were ASA I - II and planned for orthopaedic procedures under general anaesthesia were recruited. Patients were randomized into 2 groups: Group D received intravenous (IV) dexmedetomidine 1 µg/ kg (n=30) preoperatively or Group P received normal saline (n=30) instead. Both groups were induced with standardised IV induction agents and anaesthesia maintained with Sevoflurane, titrated using the bispectral index scale. The expired fraction of sevoflurane and haemodynamic parameters were recorded at 5-minute intervals intraoperatively. Postoperatively, postoperative pain score (VAS) was documented at 30 minutes recovery. Results: Our study showed a 27.8% reduction in the intraoperative expired fraction of sevoflurane requirement in group D versus 11.5% reduction in Group P (p < 0.001) and a lower mean heart rate in Group D as compared to Group P [mean (CI): 69.20 (64.03, 74.37) versus 82.00 (72.12, 91.87) per minute, p = 0.00]. The mean (SD) VAS for 30 minutes postoperative pain was significantly lower in group D when compared to group P [1.507(0.275) vs 2.209(0.403), p = 0.00]. Conclusion: This study has shown that a single dose of pre-induction dexmedetomidine was able to significantly reduce anaesthetic requirement of sevoflurane and mean heart rate intraoperatively and postoperative pain.

Cardiac Tamponade: A Rare Complication of Plasmodium Knowlesi Malaria

Abstract@#Plasmodium knowlesi has been discovered as the fifth species causing malaria in humans. It is a major public health problem in South East Asia especially in Borneo. We report a case of pericardial effusion that rapidly progressing to cardiac tamponade, an atypical presentation of P. knowlesi malaria. Our patient had no underlying known medical illness, presented with high grade fever with chills and rigors, epigastric pain, nausea, vomiting and with poor oral intake. Initial bedside cardiac ultrasound showed minimal pericardial effusion. Within a few hours, she became hypotensive, deteriorated rapidly despite fluid resuscitation requiring mechanical ventilation and inotropic support. Bedside cardiac ultrasound showed cardiac tamponade and pericardiocentesis was done. We highlight the importance of having high level of suspicion for this atypical presentation of cardiac tamponade when a patient is hypotensive in P. knowlesi infection. Prompt diagnosis and management may prevent potentially fatal complication.

Determining the Merit of Inferior Vena Cava Distensibility Index in The Estimation of Fluid Responsiveness in Ventilated Septic Patient in Intensive Care Unit

@#Introduction: There is no single haemodynamic parameters either static central venous pressure (CVP) or dynamic stroke volume variation, inferior vena cava distensibility index (SVV,IVCd) that can be used precisely to assess fluid responsiveness. It must be performed concurrently with clinical assessment. Therefore, this study was conducted to determine the correlation between these 3 parameters. Methods: This was a cross sectional non-interventional study conducted in intensive care unit. Each patient who fulfilled the criteria will have their CVP, SVV and IVCd measured instantaneously. Analysis of correlation was done using bivariate (Pearson) correlation, while agreement between SVV and IVCd was assessed using Cohen’s Kappa analysis. Results: A total of 37 patients were enrolled in this study. 70.3% were males and 29.7% were females. Mean age was 59.7 ± 13.3. Mean APACHE score was 24.1 ± 6.1. IVCd had significant positive correlation with SVV (r = 0.391, p = 0.017). Agreement between IVCd and SVV was 0.329 (0.95 CI = 0.0174 – 0.6412; p = 0.033). There was non-significant negative correlation between IVCd with CVP and SVV with CVP with r = -0.155 (p=0.359) and r = -0.068 (p= 0.691) respectively. Conclusion: There is only fair correlation between IVCd and SVV in determining fluid responsiveness. However, CVP does not correlate to both SVV and IVCd. Neither one of them is a good method in assessing fluid responsiveness during standard care in our centre. Therefore, the usage of above methods needs to combine with clinical parameters to yield better result.

Awake fibre Optic Intubation with Dexmedetomidine for Ludwig Angina with Severe Trismus

@#Ludwig angina is a submandibular space cellulitis secondary to oral cavity infection. It is strongly associated with difficult intubation due to limitation in the mouth opening. The presentation of Ludwig angina varies according to the severity of the infection. The extreme presentations include upper airway obstruction and respiratory failure. We present a female teenager with right submandibular abscess as the consequence of Ludwig angina, who was planned for incision and drainage. Successful awake fibre optic intubation was performed as a method of induction due to trismus, deferring the need for tracheostomy.

A Comparison Between Measured Maxillopharyngeal Angle On Lateral Cervical Radiograph with Modified Mallampati Classification In Predicting Difficult Larnygoscopy: A Blinded Interventional Study

@#Background: Existing techniques of predicting difficult laryngoscopy are inadequate requiring evaluation of Maxillopharyngeal Angle (MP-A) on lateral cervical radiograph described. Objectives: This study aimed to compare MP-A test with Modified Mallapati Test (MMT) in predicting their diagnostic values and Area Under Curve of Receiver Operating Characteristic Curve (AUCROCC) of both test. Methods: This is a double blinded interventional study of 93 patients. Each patient’s MMT score was assessed during preoperative assessment and subsequent MP-A test done by obtaining lateral cervical radiograph with the head in neutral position. Laryngeal view was assessed using Cormack-Lehane grade after induction of anesthesia, was used as reference standard to determine the diagnostic values of MMT and MP-A respectively. Results: The MP-Acompared to MMT in predicting difficult larngoscopy had higher sensitivity (77.78 vs 44.44) specificity (88.10 vs 67.86) and accuracy (87.10 vs 65.59) with higher Odd Ratio(26.12 vs 1.68). The AUCROCC was significantly higher in MP-A test 0.83(95%CI: 0.67, 0.99) (P = 0.001) vs MMT 0.56(95%CI: 0.36, 0.76) (P = 0.546) with LR+ of 6.53 vs 1.38. Conclusion: The Maxillopharyngeal Angle test was superior in predicting difficult laryngoscopy as compared to Modified Mallampati Test.difficult intubation

Novel Usage of Dexmetomidine In A Paediatric Patient With Giant Tongue Haemangioma

Giant haemangioma of the tongue is a disease which can obstruct the oropharyngeal airway and is presented with obstructive symptoms. Due to its vascularity, inserting laryngoscope for intubation can cause high risks, such as inducing bleeding. Hypoxia and excessive bleeding must be anticipated while securing the airway. We present a case of novel usage of dexmetomidine as a conscious sedation agent for awake fibre optic intubation in a 9-year-old child with obstructive symptoms secondary to a huge tongue haemangioma, who was presented for interventional sclerotherapy of the lesion.