Off-Pump Coronary Artery Bypass Grafting Surgery: A Valuable 2-Day Experience.

Currently, coronary artery disease (CAD) has been identified as the leading cause of mortality in Malaysia and in other countries worldwide. Genetic predisposition and comorbidities such as hypertension and diabetes mellitus, gender, lifestyle, and several other risk factors can contribute to the development of CAD. Pharmacological and surgical treatments play a vital role in improving the quality of life of patients with CAD. New surgical techniques and continuous interventions have been introduced to improve the treatment outcome. Recently, cardiothoracic teams from Universiti Teknologi MARA (UiTM) and Universiti Sains Malaysia (USM) have conducted a 2-day live workshop on off-pump coronary artery bypass (OPCAB) surgery. In this brief communication, we share the highlights and clinical tips of the OPCAB surgery gained from the collaboration.

Palliative brachytherapy to axilla and hypopharynx in elderly patient with hypopharyngeal squamous cell carcinoma - case report.

Brachytherapy (BT) is an important local treatment of tumor and it can be applied to different anatomical sites either in a curative or palliative setting. BT can deliver large dose of radiation to the tumor while sparing the surrounding normal tissue which translates into a better therapeutic ratio compared to external beam radiotherapy. However, the evidence for the use of brachytherapy in the palliative setting is lacking in the literature. In this case report, we describe the brachytherapy technique and outcome of a patient with squamous cell carcinoma of the hypopharynx who underwent palliative brachytherapy to the hypopharynx and metastatic tumor at the right axilla.

Safety and Efficacy of Intravenous Iron Sucrose versus Low Molecular Weight Iron Dextran for Treatment of Iron Deficiency Anemia in Pregnancy: A Randomized Controlled Trial.

OBJECTIVE: This study aimed to compare the efficacy, side effects, and clinical outcomes between parenteral iron sucrose complex (ISC) and low-molecular-weight iron dextran (LMWID) for iron deficiency anemia (IDA) in pregnancy. METHODS: The study was conducted in a Malaysian tertiary hospital for a period of 1 year. Forty pregnant women with IDA between 24 and 38 weeks of gestation were randomized into two groups receiving treatment with either ISC or LMWID. RESULTS: No significant difference was found between the groups in terms of demographic data, parity, and mean gestational age. A mean total of 835 ± 150 mg doses of ISC and 656 ± 382 mg doses of LMWID were administered (P = 0.0001). Adverse events were reported in five patients who received LMWID and none in those treated with ISC (P = 0.024). The mean hemoglobin (Hb) level increment 2 weeks post treatment was higher among those who received ISC than in those who received LMWID. The ISC group demonstrated an increase of 1.91 ± 1.10 g/dL (from 8.43 ± 1.03 g/dL to 10.29 ± 0.90 g/dL) compared with the LMWID group at 1.39 ± 0.54 g/dL (from 8.61 ± 0.70 g/dL to 9.92 ± 0.88 g/dL, P = 0.023). All participants in both groups delivered at term. The estimated blood loss during delivery was significantly higher in the LMWID group (359 ± 247 mL) than in the ISC group (280 ± 100 mL, P = 0.026). Otherwise, no significant difference was observed in terms of Hb level during delivery and the perinatal outcomes for both groups. CONCLUSION: Parenteral ISC is more effective than LMWID in treating maternal IDA, and it is associated with fewer adverse events.

Lumbar tinea versicolor and spinal anaesthesia.

Infection to the meningeal layer causing meningitis is one of the most feared complications of spinal anaesthesia. Anaesthetists will avoid spinal anaesthesia for those who are having skin infection at the puncture site. However in obstetric population, anaesthetist will try their best to avoid general anaesthesia due to its unwanted effects and complications. Strict and appropriate antiseptic measures such as chlorhexidine 0.5% with 70% alcohol has been suggested to reduce risk of transmission of microorganisms into subarachnoid space. We reported a parturient who had generalized tinea versicolor at the lumbar area, safely anaesthetized under spinal anaesthesia through meticulous antiseptic skin preparation who required delivery by caesarean section.

Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience.

BACKGROUND: Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding. METHODS: Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed. RESULTS: rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa. CONCLUSIONS: rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.

Sugammadex Rescue in Avoiding Intensive Care Unit Admission in an Octogenarian Undergoing Emergency Laparotomy.

Postlaparotomy management for elderly patients with underlying comorbidities is always a challenge because of poor cardiorespiratory reserves and prolonged effect of anesthetic drugs. For these reasons, such patients usually require intensive care unit (ICU) admission in the postoperative period. We report a case of an 85-year-old chronic smoker with controlled diabetes mellitus who needed an emergency laparotomy for a perforated gastric ulcer. Unfortunately, there was a shortage of ICU backup. With the successful conduct of an early surgery using combined general and regional anesthesia, the use of sugammadex (Bridion, Merck Sharp & Dohme Corp, Oss, the Netherlands) as a reversal agent, a skilled surgeon, and good postanesthesia care, the patient did not require ICU admission. He recovered fast and was discharged home 4 days after surgery. This case study aims to contribute to the literature on experience of a successful conduct of anesthesia in a high-risk geriatric patient when ICU facilities are limited.

Brachytherapy of tongue carcinoma in a patient with difficult airway: anesthetic considerations.

The practice of brachytherapy in unresectable tongue carcinoma is gaining popularity. However, this procedure poses specific anesthetic challenges, particularly challenges of airway sharing and a higher rate of difficult airway. We report a 74-year-old chronic smoker, chronic alcoholic with history of stroke, who had undergone brachytherapy for tongue carcinoma. Apart from a huge tongue tumor, he had an epiglottic mass but refused elective tracheostomy. This had led to a few critical states throughout the process of treatment, including a metabolic crisis due to thiamine deficiency and difficult airway crisis. To our best knowledge, there have been no reported case on a patient with vocal cord mass undergoing tongue brachytherapy. We hope sharing of this experience may aid the management of similar patients in future.

Acute bacteremic pneumonia due to melioidosis developing in the intensive care setting.

In Malaysia, melioidosis is commonly encountered as this infection is known as part of the endemic area for the disease. Managing cases of positive Burkholderia pseudomallei infection can involve multidisciplinary unit mainly, microbiologist, infectious disease team and intensive care as it may be quite difficult to distinguish melioidosis from a number of other diseases on the clinical setting alone. Laboratory diagnosis plays a vital role in determining the direction of management. Investigations such as culture, polymerase chain reaction (PCR) and serology should be evaluated once the disease is suspected. In this particular case, the patient is a young adult involved in a road traffic accident. Unlike any other cases with melioidosis, he had no potential risk factors which may have contributed to the severity of the disease and it is likely that the site of the accident was the source of acquisition of this gram negative bacterium.

The dangers of accepting a single diagnosis: case report of concurrent Plasmodium knowlesi malaria and dengue infection.

BACKGROUND: Dengue and malaria are two common, mosquito-borne infections, which may lead to mortality if not managed properly. Concurrent infections of dengue and malaria are rare due to the different habitats of its vectors and activities of different carrier mosquitoes. The first case reported was in 2005. Since then, several concurrent infections have been reported between the dengue virus (DENV) and the malaria protozoans, Plasmodium falciparum and Plasmodium vivax. Symptoms of each infection may be masked by a simultaneous second infection, resulting in late treatment and severe complications. Plasmodium knowlesi is also a common cause of malaria in Malaysia with one of the highest rates of mortality. This report is one of the earliest in literature of concomitant infection between DENV and P. knowlesi in which a delay in diagnosis had placed a patient in a life-threatening situation. CASE PRESENTATION: A 59-year old man staying near the Belum-Temengor rainforest at the Malaysia-Thailand border was admitted with fever for 6 days, with respiratory distress. His non-structural protein 1 antigen and Anti-DENV Immunoglobulin M tests were positive. He was treated for severe dengue with compensated shock. Treating the dengue had so distracted the clinicians that a blood film for the malaria parasite was not done. Despite aggressive supportive treatment in the intensive care unit (ICU), the patient had unresolved acidosis as well as multi-organ failure involving respiratory, renal, liver, and haematological systems. It was due to the presentation of shivering in the ICU, that a blood film was done on the second day that revealed the presence of P. knowlesi with a parasite count of 520,000/µL. The patient was subsequently treated with artesunate-doxycycline and made a good recovery after nine days in ICU. CONCLUSIONS: This case contributes to the body of literature on co-infection between DENV and P. knowlesi and highlights the clinical consequences, which can be severe. Awareness should be raised among health-care workers on the possibility of dengue-malaria co-infection in this region. Further research is required to determine the real incidence and risk of co-infection in order to improve the management of acute febrile illness.

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.

Difficult mask ventilation: simple step to make the impossible, possible!

Mask ventilation is one of the most important skills in airway management. Difficulty in mask ventilation can become life threatening if it is associated with difficulty in intubation during general anesthesia. We report a potential impossible ventilation condition which was safely and easily overcome with appropriate innovative modification of an Opsite adhesive film.