Does Epidural During Labour Lead To Chronic Low Backpain? A Malaysian Retrospective Study

@#Introduction: The question as to whether epidural analgesia during labour can cause chronic low backpain has become a concern lately but this association has not been tested locally and remains controversial. This retrospective study aimed to ascertain the relationship between labour epidural analgesia and development of subsequent chronic low backpain. Methods: We contacted 200 primiparous women who had delivered by normal vaginal delivery via telephone at six months after delivery. While 100 of them had previously received epidural analgesia for labour, the other 100 had not. The women had to quantify their backpain by yes/no responses, numeric rating score, and impairment of daily function. Both the epidural and the non-epidural groups were compared using independent t-test and Chi-squared test while logistic regression was used to control for confounding factors. Results: The two groups had similar baseline characteristics except for body mass index, employment status and labour duration. The women who received epidural analgesia had significantly higher prevalence of low backpain at six months after delivery than those who had not (28% versus 9%, P = 0.001). However, the two groups did not show any difference in terms of numeric rating score or level of impairment of daily function. The low back pain at six months (epidural versus non-epidural) had an adjusted odds ratio of 8.1 (95% confidence interval 2.7 to 24.0, P <0.001). Conclusion: While epidural analgesia during labour was shown to be associated with chronic low back pain, this association may not be causal, suggesting the need for a randomized-controlled study in this area.

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.

Validation of the 28-day mortality prognostic performance of the modified Nutrition Risk in Critically Ill (mNUTRIC) score in a Malaysian intensive care unit

@#Introduction: The mNUTRIC score is a nutritional assessment tool to identify critically ill patients with high nutritional risk who could benefit from nutritional interventions. This study was conducted to validate the 28-day mortality prognostic performance of the mNUTRIC score in a Malaysian intensive care unit (ICU). Methods: This was a retrospective cohort study of adult patients who were consecutively admitted to the ICU from January 2017 to December 2018 for >24 hours. Data were collected on variables required to calculate the mNUTRIC score. Patients with mNUTRIC score ≥5 points were considered to be at high nutritional risk. Main outcome was 28- day mortality from all causes; ICU length of stay (LOS) and prolonged mechanical ventilation (MV) (>2 days) were secondary outcomes. Results: From a total of 432 admissions, 382 (88.4%) patients fulfilled the study criteria. Seventy-seven (20.2%) of these patients were at high nutritional risk. They had longer mean ICU LOS (7.1±7.5 days versus 4.2±4.0 days, p=0.001), greater proportion of prolonged MV (57.1% versus 14.4%, p<0.001) and higher 28-day mortality (44.2% versus 10.2%, p<0.001) compared to patients with low mNUTRIC score (≤4 points). High mNUTRIC score predicted 28-day mortality with area under the curve (AUC) of 0.797 (95% confidence interval: 0.738-0.856). Conclusion: High mNUTRIC score was associated with a higher 28-day mortality. The prognostic performance for 28-day mortality of the mNUTRIC score is clinically valid as indicated by AUC >0.7 and is comparable to the results of other validation studies. In addition, patients with high mNUTRIC score had increased ICU LOS and prolonged MV.

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 neurointensive 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.

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.