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Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.
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BACKGROUND: Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS: This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS: There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS: Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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BACKGROUND: Rib fractures are common sequelae after blunt chest wall trauma. They can occur in isolation or association with life-threatening injuries to the head, thorax, and abdomen and may be complicated by hemothorax, pneumothorax, or lung contusions. Contiguous rib fractures can result in flail chest, which is associated with increased morbidity and mortality. This study aims to compare the risk factors, treatment modalities, and outcomes between patients with flail chest and nonflail chest postblunt trauma. PATIENTS AND METHODS: Data were retrospectively collected from all patients admitted with rib fractures from January 2016 to December 2016 to the Department of General Surgery, Khoo Teck Puat Hospital, Singapore. The outcomes identified were mortality, pain scores on injury day 1, 3, 5, and 7, injury severity score, duration of mechanical ventilation, worst partial pressure arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, length of intensive care unit (ICU) stay, and pulmonary complications. RESULTS: Motor vehicle accident was the most common cause of rib fractures (63.1%, n = 123). Patients with flail chest had more associated pneumothorax (53.8% vs. 35.2%) and lung contusions (53.8% vs. 30.2%) compared to those without flail chest and underwent more investigations such as inpatient-computed tomography scans (76.9% vs. 59.3%), interventions such as chest tube insertion (61.5% vs. 19.8%), and ICU admission (46.1 vs. 13.7%). Patients also had higher pain scores, used more analgesic modalities, and had increased inpatient mortality (30.8% vs. 4.4%). CONCLUSION: Flail chest is associated with higher morbidity and mortality. Proactive management from a multidisciplinary team such as identification of high-risk patients in particular patients with flail chest, early admission to critical care, and protocols including multimodal pain management, respiratory support, and rehabilitation should be instituted.
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INTRODUCTION: Airway management during anaesthesia has potential difficulties and risks. We aimed to investigate the utility of routine airway assessment for predicting difficult tracheal intubation, review the prevailing practice of videolaryngoscope use amongst anaesthetists in a teaching hospital and determine the incidence of intraoperative and postoperative airway-related complications. METHODS: A prospective observational study of 1,654 patients undergoing general anaesthesia with endotracheal intubation over a seven-month period was performed. Data regarding airway and anaesthetic management was collected and analysed. RESULTS: Videolaryngoscopes were used as the first-choice equipment in 60.5% of the cohort. The incidence of difficult intubation was 2.1%, of which 45.7% of cases were unanticipated. The sensitivity of airway assessment was 54.3%, with a positive predictive value of 8.1%. When difficult intubation was anticipated, more videolaryngoscopes were used as the first equipment of choice compared to the Macintosh laryngoscope (p < 0.001). In the Macintosh group, more patients required a change of airway equipment (p = 0.015), but the number of intubation attempts was similar (p = 0.293). The incidence of intraoperative (p = 0.920) and postoperative complications (p = 0.380) were similar in both groups. CONCLUSION: Using the current predictors of difficult intubation, half of the difficult airways we encountered were unanticipated. Videolaryngoscopes were preferred when difficulty was anticipated and were also used in routine tracheal intubation.
