Chikungunya virus-associated death in Malaysia.

Chikungunya virus (CHIKV) is a mosquito-borne alphavirus which causes fever, rash, and arthralgia. In the past, life-threatening complications were very rarely reported. However, during the recent worldwide outbreaks, there have been several reports of unusually severe complications and deaths. Malaysia is experiencing a nationwide outbreak of CHIKV, with over 10 000 patients affected since April 2008. We report the first case of culture-confirmed CHIKV-associated death in Malaysia, in a patient with fever, rash, acute exacerbation of pre-existing heart failure, rhabdomyolysis, and multiple organ failure. CHIKV infections may cause atypical, severe or fatal presentations.

Comparison of propofol consumption and recovery time in Caucasians from Italy, with Chinese, Malays and Indians from Malaysia.

Differences in sensitivity to anaesthetic drugs may exist among different ethnic groups. Allelic variants for drug metabolizing isoenzymes and pharmacokinetic differences may account for a variable response to some anaesthetic drugs. This study was designed to compare propofol consumption and recovery characteristics in four ethnic groups: Chinese, Malays, and Indians in Malaysia and Caucasians in Italy. Patients undergoing total intravenous anaesthesia with propofol and fentanyl were evaluated for propofol consumption and recovery time. The Bispectral Index (BIS) was used to maintain the same anaesthesia depth in all patients. The BIS value, the response to verbal stimuli and eye-opening time were used to assess recovery. After propofol discontinuation the BIS values returned to baseline in 11+/-4.2 min for Caucasians, in 12.5+/-5.1 min for Chinese, 15.9+/-6.3 min for Malays and 22.1+/-8.1 for Indians. Time to eye-opening was 11.63+/-4.2 min in Caucasians, 13.23+/-4.9 min in Chinese, 16.97+/-5.2 min in Malays and 22.3+/-6.6 min in Indians. The propofol consumption was significantly lower in Indians compared to the other three groups (P<0.01). The recovery of Indians was much slower compared to Chinese, Malays and Caucasians. The recovery time of Malays is significantly slower compared to Chinese and Caucasians. Differences in propofol consumption and recovery time were not significant between Chinese and Caucasians, but the ratio recovery time/propofol consumption was significantly lower in Caucasians compared to all the other groups.

Acute respiratory failure in melioidosis.

BACKGROUND: In melioidosis caused by Burkholderia pseudomallei, although every organ in the body may be involved, the highest mortality of 73% occurs when the respiratory system is affected. These patients invariably die of acute respiratory failure. Most of them also have underlying predisposing factors like diabetes mellitus. AIM OF STUDY: A retrospective study of six such cases was carried out in order to elicit the possible causes and mechanisms of acute respiratory failure in patients with melioidosis. METHOD: Patients' records were reviewed for demographic, clinical, laboratory, radiological and histopathological data. RESULTS: The rapidity of onset of respiratory failure was remarkable and was accompanied by relentless hypoxaemia that was refractory to treatment despite the application of high positive end expiratory pressure and other supportive measures. All had bilateral opacities on frontal chest radiographs, focal and diffuse necrotizing pneumonia and presence of hyaline membranes in lung tissues seen histologically, supporting the accepted criteria for ALI/ARDS. CONCLUSION: Patients with sepsis due to B. pseudomallei develop ALI/ARDS very rapidly resulting in high mortality rates. Possible mechanisms involved are discussed. Awareness of the disease in endemic areas, the development of rapid diagnostic methods and appropriate management procedures are urgently needed for the prevention of ARDS and subsequent reduction in mortality in such cases.

Subcutaneous emphysema and pneumomediastinum after endotracheal anaesthesia.

INTRODUCTION: We report a case of subcutaneous emphysema and pneumomediastinum that presented postoperatively after tracheal extubation. CLINICAL PICTURE: A 51-year-old man had an uneventful anaesthesia lasting about 6.5 hours. Intubation was performed by a very junior medical officer and was considered difficult. He developed sore throat, chest pain, numbness of both hands and palpable crepitus around the neck postoperatively. Chest X-ray revealed diffuse subcutaneous emphysema, pneumomediastinum and possible pneumopericardium. TREATMENT: He was treated conservatively with bed rest, oxygen, analgesia, antibiotic prophylaxis, reassurance and close monitoring. OUTCOME: The patient made an uneventful recovery. CONCLUSIONS: We discussed the possible causes.

A comparison of the maintenance and recovery charcateristic of sevoflurane-nitrous oxide against isoflurane-nitrous oxide anaesthesia.

BACKGROUND: To compare the maintenance and recovery characteristics of sevoflurane and isoflurane anaesthesia in Malaysian patients. METHOD: This is a prospective, open labelled, randomized, controlled study. Sixty unpremedicated ASA I or II patients (aged 18-50 years), scheduled for elective breast lump excision were randomly allocated to receive either isoflurane or sevoflurane for the maintenance of anaesthesia following fentanyl and propofol intravenous induction. The systolic, diastolic, mean arterial blood pressure and heart rate were measured. The speed of recovery was measured by time to eye opening, time to following simple command, and time to correctly giving own names and address. The incidence of postoperative complication was also recorded. RESULTS: The trend of systolic blood pressure was significantly higher in the isoflurane group as compared to the sevoflurane group for the duration of anaesthesia (p < 0.001, by ANOVA for repeated measurement) but the trend of heart rate was similar for both groups. The recovery time was faster in the isoflurane group. [mean time of eye opening (SD) = 6.8 (2.2) vs 10.7 (4.4) min, p < 0.001; mean time of sticking tongue out (SD) = 7.9 (2.9) vs 11.5 (4.7) min, p < 0.01; mean time of giving own name (SD) = 7.8 (2.7) vs 11.8 (4.8) min, p < 0.001, mean time of giving own address (SD) = 8.4 (2.9) vs 12.0 (4.7) min, p < 0.01]. No major adverse effects were encountered postoperatively and the incidences of minor adverse effects were low in both groups. CONCLUSION: We concluded that sevoflurane is a safe alternative to isoflurane but in these short procedures, awakening time was surprisingly slower than after isoflurane.

Epidural anaesthesia for caesarean section: a comparison of 0.5% bupivacaine plain, 0.5% bupivacaine plus 100 micrograms fentanyl and 0.5% bupivacaine plus 50 micrograms fentanyl.

Thirty-one healthy women who underwent Caesarean section were studied in a double-blind trial to compare the effectiveness of epidural 0.5% bupivacaine plain, 0.5% bupivacaine plus 100 micrograms fentanyl and 0.5% bupivacaine plus 50 micrograms fentanyl in the prevention of intraoperative pain. There was no difference in the quality of analgesia between the three groups. The incidence of complications was significantly higher in the 0.5% bupivacaine plus 100 micrograms fentanyl group compared with the other two groups.

Evaluation of the bacteriological contamination of a closed feeding system for enteral nutrition.

A closed enteral delivery system consisting of a cardboard tetrapack containing the sterile ready-to-use liquid feed and an independent sterile administration set, has been devised. We found bacterial contamination within 24 hours in this system in patients on ventilatory support in intensive care. This emphasises the need for meticulous care in handling enteral feeding systems to prevent environmental contamination.

Severe bronchospasm during epidural anaesthesia.

A case of severe bronchospasm occurring during epidural anaesthesia in a patient undergoing Caesarean section is described. The aetiology of the bronchospasm may have been related to sympathetic nervous blockade allowing unopposed parasympathetically mediated bronchoconstriction.