Effective Antimicrobial StewaRdship StrategIES (ARIES): Cluster Randomized Trial of Computerized Decision Support System and Prospective Review and Feedback.

BACKGROUND: Prospective review and feedback (PRF) of antibiotic prescriptions and compulsory computerized decision support system (CDSS) are 2 strategies of antimicrobial stewardship. There are limited studies investigating their combined effects. We hypothesized that the use of on-demand (voluntary) CDSS would achieve similar patient outcomes compared with automatically triggered (compulsory) CDSS whenever broad-spectrum antibiotics are ordered. METHODS: A parallel-group, 1:1 block cluster randomized crossover study was conducted in 32 medical and surgical wards from March to August 2017. CDSS use for piperacillin-tazobactam or carbapenem in the intervention clusters was at the demand of the doctor, while in the control clusters CDSS use was compulsory. PRF was continued for both arms. The primary outcome was 30-day mortality. RESULTS: Six hundred forty-one and 616 patients were randomized to voluntary and compulsory CDSS, respectively. There were no differences in 30-day mortality (hazard ratio [HR], 0.87; 95% CI, 0.67-1.12), re-infection and re-admission rates, antibiotic duration, length of stay, or hospitalization cost. The proportion of patients receiving PRF recommendations was not significantly lower in the voluntary CDSS arm (62 [10%] vs 81 [13%]; P = .05). Appropriate indication of antibiotics was high in both arms (351/448 [78%] vs 330/433 [74%]; P = .18). However, in geriatric medicine patients where antibiotic appropriateness was <50%, prescription via compulsory CDSS resulted in a shorter length of stay and lower hospitalization cost. CONCLUSIONS: Voluntary broad-spectrum antibiotics with PRF via CDSS did not result in differing clinical outcomes, antibiotic duration, or length of stay. However, in the setting of low antibiotic appropriateness, compulsory CDSS may be beneficial.

Management plan to reduce risks in perioperative care of patients with obstructive sleep apnoea averts the need for presurgical polysomnography.

INTRODUCTION: Obstructive sleep apnoea (OSA) is associated with increased perioperative morbidity and mortality. Patients at risk of OSA as determined by pre-anaesthesia screening based on the American Society of Anesthesiologists checklist were divided into 2 groups for comparison: (i) those who proceeded to elective surgery under a risk management protocol without undergoing formal polysomnography preoperatively and; (ii) those who underwent polysomnography and any subsequent OSA treatment as required before elective surgery. We hypothesised that it is clinically safe and acceptable for patients identified on screening as OSA at-risk to proceed for elective surgery without delay for polysomnography, with no increase in postoperative complications if managed on a perioperative risk reduction protocol. MATERIALS AND METHODS: A retrospective review of patients presenting to the preanaesthesia clinic over an 18-month period and identified to be OSA at-risk on screening checklist was conducted (n = 463). The incidence of postoperative complications for each category of OSA severity (mild-moderate and severe) in the 2 study groups was compared. RESULTS: There was no statistically significant difference in the incidence of cardiac (3.3% vs 2.3%), respiratory (14.3% vs 12.5%), and neurologic complications (0.6% vs 0%) between the screening-only and polysomnography-confirmed OSA groups respectively (P >0.05). There was good agreement of the OSA risk that is identified by screening checklist with OSA severity as determined on formal polysomnography (kappa coefficient = 0.953). CONCLUSION: Previously undiagnosed OSA is common in the presurgical population. In our study, there was no significant increase in postoperative complications in patients managed on the OSA risk management protocol. With this protocol, it is clinically safe to proceed with elective surgery without delay for formal polysomnography confirmation.

The transplantable organ shortage in Singapore: has implementation of presumed consent to organ donation made a difference?

The success of solid organ transplantation in the treatment of end-stage organ failure has fuelled a growing demand for transplantable organs worldwide that has far outstripped the supply from brain dead heart-beating donors. In Singapore, this has resulted in long waiting lists of patients for transplantable organs, especially kidneys. The Human Organ Transplant Act, introduced in 1987, is an opt-out scheme that presumes consent to removal of certain organs for transplantation upon death. Despite this legislation, the number of deceased organ donors in Singapore, at 7 to 9 per million population per year, remains low compared to many other developed countries. In this paper, we reviewed the clinical challenges and ethical dilemmas encountered in managing and identifying potential donors in the neurological intensive care unit (ICU) of a major general hospital in Singapore. The large variance in donor actualisation rates among local restructured hospitals, at 0% to 56.6% (median 8.8%), suggests that considerable room still exists for improvement. To address this, local hospitals need to review their processes and adopt changes and best practices that will ensure earlier identification of potential donors, avoid undue delays in diagnosing brain death, and provide optimal care of multi-organ donors to reduce donor loss from medical failures.

Anaesthetic management of awake craniotomy for tumour resection.

INTRODUCTION: Awake craniotomy allows accurate localisation of the eloquent brain, which is crucial during brain tumour resection in order to minimise risk of neurologic injury. The role of the anaesthesiologist is to provide adequate analgesia and sedation while maintaining ventilation and haemodynamic stability in an awake patient who needs to be cooperative during neurological testing. We reviewed the anaesthetic management of patients undergoing an awake craniotomy procedure. MATERIALS AND METHODS: The records of all the patients who had an awake craniotomy at our institution from July 2004 till June 2006 were reviewed. The anaesthesia techniques and management were examined. The perioperative complications and the outcome of the patients were noted. RESULTS: There were 17 procedures carried out during the study period. Local anaesthesia with moderate to deep sedation was the technique used in all the patients. Respiratory complications occurred in 24% of the patients. Hypertension was observed in 24% of the patients. All the complications were transient and easily treated. During cortical stimulation, motor function was assessed in 16 patients (94%). Three patients (16%) had lesions in the temporal-parietal region and speech was assessed intraoperatively. Postoperative motor weakness was seen in 1 patient despite uneventful intraoperative testing. No patient required intensive care unit stay. The median length of stay in the high dependency unit was 1 day and the median length of hospital stay was 9 days. There was no in-hospital mortality. CONCLUSION: Awake craniotomy for brain tumour excision can be successfully performed under good anaesthetic conditions with careful titration of sedation. Our series showed it to be a well-tolerated procedure with a low rate of complications. The benefits of maximal tumour excision can be achieved, leading to potentially better patient outcome.

A survey of brain death certification--an impetus for standardisation and improvement.

INTRODUCTION: Despite well-established guidelines, multiple recent studies have demonstrated variability in the conduct of brain death certification. This is undesirable given the gravity of the diagnosis. We sought therefore to survey local clinicians involved in brain death certification to identify specific areas of variability, if any, and to elicit information on how the testing process can be improved. MATERIALS AND METHODS: An anonymous questionnaire was sent to all clinicians on the brain death certification roster in a tertiary neurosciences referral centre. This survey covered clinician demographics, evaluation of current and proposed resources to assist clinicians in certification, knowledge of the legislation governing brain death and organ procurement, technical performance of the brain death tests, and their views on the appropriate limits of physiological and biochemical preconditions for brain death testing. RESULTS: We found significant variability in the conduct of brain death testing, especially in performing the caloric and apnoea tests. Of the existing resources to assist clinicians, written aide-memoires were the most popular. Respondents felt that bedside availability of a more detailed written description of the brainstem tests, and a formal accreditation course would be useful. There was wide variation in the limits of serum sodium and glucose, and the minimum core temperature and systolic blood pressures that respondents felt would preclude testing but we were able to identify thresholds at which the majority would be happy to proceed. We addressed the issues identified in our study by improving our written hospital brain death protocol, and designing an instructional course for clinicians involved in brain death certification. CONCLUSIONS: Our findings confirm that variability in the performance of brain death testing is indeed a universal phenomenon. Formal training appears desirable, but more importantly, clear and detailed protocols for testing should be made available at the bedside to assist clinicians. These protocols should be tailored to provide step-by-step instructions so as to avoid the inconsistencies in testing identified by this and other similar studies.

Acute respiratory distress syndrome in critically ill patients with severe acute respiratory syndrome.

CONTEXT: Severe acute respiratory syndrome (SARS) is an emerging infectious disease with a 25% incidence of progression to acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) and mortality exceeding 10%. OBJECTIVE: To describe the clinical spectrum and outcomes of ALI/ARDS in patients with SARS-related critical illness. DESIGN, SETTING, AND PATIENTS: Retrospective case series of adult patients with probable SARS admitted to the intensive care unit (ICU) of a hospital in Singapore between March 6 and June 6, 2003. MAIN OUTCOME MEASURES: The primary outcome measure was 28-day mortality after symptom onset. RESULTS: Of 199 patients hospitalized with SARS, 46 (23%) were admitted to the ICU, including 45 who fulfilled criteria for ALI/ARDS. Mortality at 28 days for the entire cohort was 20 (10.1%) of 199 and for ICU patients was 17 (37%) of 46. Intensive care unit mortality at 13 weeks was 24 (52.2%) of 46. Nineteen of 24 ICU deaths occurred late (> or =7 days after ICU admission) and were attributed to complications related to severe ARDS, multiorgan failure, thromboembolic complications, or septicemic shock. ARDS was characterized by ease of derecruitment of alveoli and paucity of airway secretion, bronchospasm, or dynamic hyperinflation. Lower Acute Physiology and Chronic Health Evaluation II scores and higher baseline ratios of PaO2 to fraction of inspired oxygen were associated with earlier recovery. CONCLUSIONS: Critically ill patients with SARS and ALI/ARDS had characteristic clinical findings, high rates of complications; and high mortality. These findings may provide useful information for optimizing supportive care for SARS-related critical illness.