Mohd Basri Mat Nor

Procalcitonin Clearance for Early Prediction of Survival in Critically Ill Patients with Severe Sepsis

Introduction. Serum procalcitonin (PCT) diagnosed sepsis in critically ill patients; however, its prediction for survival is not well established. We evaluated the prognostic value of dynamic changes of PCT in sepsis patients. Methods. A prospective observational study was conducted in adult ICU. Patients with systemic inflammatory response syndrome (SIRS) were recruited. Daily PCT were measured for 3 days. 48 h PCT clearance (PCTc-48) was defined as percentage of baseline PCT minus 48 h PCT over baseline PCT. Results. 95 SIRS patients were enrolled (67 sepsis and 28 noninfectious SIRS). 40% patients in the sepsis group died in hospital. Day 1-PCT was associated with diagnosis of sepsis (AUC 0.65 (95% CI, 0.55 to 0.76)) but was not predictive of mortality. In sepsis patients, PCTc-48 was associated with prediction of survival (AUC 0.69 (95% CI, 0.53 to 0.84)). Patients with PCTc-48 > 30% were independently associated with survival (HR 2.90 (95% CI 1.22 to 6.90)). Conclusions. PCTc-48 is associated with prediction of survival in critically ill patients with sepsis. This could assist clinicians in risk stratification; however, the small sample size, and a single-centre study, may limit the generalisability of the finding. This would benefit from replication in future multicentre study.Introduction. Serum procalcitonin (PCT) diagnosed sepsis in critically ill patients; however, its prediction for survival is not well established. We evaluated the prognostic value of dynamic changes of PCT in sepsis patients. Methods. A prospective observational study was conducted in adult ICU. Patients with systemic inflammatory response syndrome (SIRS) were recruited. Daily PCT were measured for 3 days. 48 h PCT clearance (PCTc-48) was defined as percentage of baseline PCT minus 48 h PCT over baseline PCT. Results. 95 SIRS patients were enrolled (67 sepsis and 28 noninfectious SIRS). 40% patients in the sepsis group died in hospital. Day 1-PCT was associated with diagnosis of sepsis (AUC 0.65 (95% CI, 0.55 to 0.76)) but was not predictive of mortality. In sepsis patients, PCTc-48 was associated with prediction of survival (AUC 0.69 (95% CI, 0.53 to 0.84)). Patients with PCTc-48 > 30% were independently associated with survival (HR 2.90 (95% CI 1.22 to 6.90)). Conclusions. PCTc-48 is associated with prediction of survival in critically ill patients with sepsis. This could assist clinicians in risk stratification; however, the small sample size, and a single-centre study, may limit the generalisability of the finding. This would benefit from replication in future multicentre study.

Acute kidney injury in a Malaysian intensive care unit: assessment of incidence, risk factors and outcome

PURPOSE Acute kidney injury (AKI) is common and carries a high mortality rate. Most epidemiological studies were retrospective and were done in Western populations. We aim to assess its incidence using both urine output and creatinine criteria and its association with risk factors and outcome. MATERIAL AND METHODS This was a single-center, prospective, observational study. All intensive care unit (ICU) patients older than 18 years were screened for inclusion in the study. Admission of less than 48 hours, postelective surgery, and ICU readmission were excluded. RESULTS A total of 143 patients were recruited, of these, 65% had AKI, of which 18 (19%) were stage 1; 23 (25%), stage 2; and 52 (56%), stage 3. Independent risk factors for AKI include high Acute Physiology and Chronic Health Evaluation II score and septic shock (odds ratio of 1.20 [1.09-1.33] and 8.41 [1.49-47.6], respectively). Thirty-eight percent were classified as AKI based on creatinine and 61% as AKI based on urine output criteria, and, in 34%, both AKI based on creatinine and AKI based on urine output criteria were present. Acute kidney injury was an independent risk factor for mortality (hazard ratio of, 2.61 [1.06-6.42]). CONCLUSIONS Acute kidney injury is common in our ICU, and almost half are of highest severity stage. Patients with high severity of illness and septic shock were at risk for AKI. The presence of AKI independently predicted mortality.

Intensive care in severe malaria: report from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

&NA; Severe malaria is common in tropical countries in Africa, Asia, Oceania and South and Central America. It may also occur in travelers returning from endemic areas. Plasmodium falciparum accounts for most cases, although P vivax is increasingly found to cause severe malaria in Asia. Cerebral malaria is common in children in Africa, manifests as coma and seizures, and has a high morbidity and mortality. In other regions, adults may also develop cerebral malaria but neurological sequelae in survivors are rare. Acute kidney injury, liver dysfunction, thrombocytopenia, disseminated intravascular coagulopathy (DIC) and acute respiratory distress syndrome (ARDS) are also common in severe malaria. Metabolic abnormalities include hypoglycemia, hyponatremia and lactic acidosis. Bacterial infection may coexist in patients presenting with shock or ARDS and this along with a high parasite load has a high mortality. Intravenous artesunate has replaced quinine as the antimalarial agent of choice. Critical care management as per severe sepsis is also applicable to severe malaria. Aggressive fluid boluses may not be appropriate in children. Blood transfusions may be required and treatment of seizures and raised intracranial pressure is important in cerebral malaria in children. Mortality in severe disease ranges from 8 to 30% despite treatment. Highlights:The nature of the organism and its parisitologyThe clinical featuresThe pathogenesisThe laboratory diagnosisThe management

Performance of STAR virtual trials for diabetic and non-diabetic in HTAA intensive care unit

Critically ill patients are commonly linked to stress-induced hyperglycaemia which relates to insulin resistance and the risk of per-diagnosed with diabetes and other metabolic illnesses. Thus, it is essential to choose the best practice of blood glucose management in order to reduce morbidity and mortality rates in intensive care unit. This study is focusing on clinical data of 210 critically ill patients in Hospital Tengku Ampuan Afzan (HTAA), Kuantan who underwent Intensive Insulin Therapy which utilized a sliding scale method. Patients were identified in two main groups of diabetic (123) and non-diabetic (87) where stochastic model is generated to observe 90% confidence interval of insulin sensitivity. Blood glucose levels comparison between these two cohorts is conducted to observe the percentage of blood glucose levels within targeted band of 4.4–10.0 mmol/L. It is found that 82% of BG levels are within tar gated band for non-diabetes cohort under stochastic targeted (STAR) glycaemic control protocol. However, only 59.6% and 70.6% BG levels are within targeted band for diabetes cohort for insulin infusion therapy used in HTAA and STAR protocols. Thus, further investigation on blood glucose control protocol for diabetes patients is required to increase the reliability and efficacy of current practice despite of patient safety.

High frequency oscillatory ventilation in leptospirosis pulmonary hemorrhage syndrome: A case series study.

Hypoxemia in severe leptospirosis-associated pulmonary hemorrhage syndrome (LPHS) is a challenging clinical scenario not usually responsive to maximal support on mechanical ventilation. We described the efficacy and safety of high frequency oscillatory ventilation (HFOV) as rescue therapy in acute respiratory failure secondary to LPHS. This is a retrospective case study of five patients with diagnosis of severe LPHS, who were admitted to Intensive Care Unit from October 2014 to January 2015. They developed refractory hypoxemia on conventional mechanical ventilation and rescue therapy was indicated. All patients responded rapidly by showing improvements in oxygen index and PaO2/FiO2 ratio within first 72 h of therapy. Despite severity of illness evidenced by high Simplified Acute Physiological II and Sequential Organ Failure Assessment scores, all patients were discharged from hospital alive. In view of the rapid onset and extent of hemorrhage which may culminate quickly into asphyxiation and death, HFOV may indeed be lifesaving in severe LPHS.

Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A consensus statement

BACKGROUND & AIMS Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia-Pacific and Middle East regions, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia-Pacific and the Middle East. METHODS The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia-Pacific and the Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions. RESULTS Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU. CONCLUSIONS The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes.

Plasma Neutrophil Gelatinase Associated Lipocalin Diagnosed Acute Kidney Injury in Patients With Systemic Inflammatory Disease And Sepsis.

Sepsis is the leading cause of intensive care unit (ICU) admission. Plasma Neutrophil Gelatinase Associated‐Lipocalin (NGAL) is a promising biomarker for acute kidney injury (AKI) detection; however, it is also increased with inflammation and few studies have been conducted in non‐Caucasian populations and/or in developing economies. Therefore, we evaluated plasma NGALs diagnostic performance in the presence of sepsis and systemic inflammatory response syndrome (SIRS) in a Malaysian ICU cohort.

Pneumonia in the tropics: Report from the Task Force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine

ABSTRACT The aetiology of community acquired pneumonia varies according to the region in which it is acquired. This review discusses those causes of CAP that occur in the tropics and might not be readily recognizable when transplanted to other sites. Various forms of pneumonia including the viral causes such as influenza (seasonal and avian varieties), the coronaviruses and the Hantavirus as well as bacterial causes, specifically the pneumonic form of Yersinia pestis and melioidosis are discussed.

Assessing mechanical ventilation asynchrony through iterative airway pressure reconstruction

BACKGROUND AND OBJECTIVE Respiratory mechanics estimation can be used to guide mechanical ventilation (MV) but is severely compromised when asynchronous breathing occurs. In addition, asynchrony during MV is often not monitored and little is known about the impact or magnitude of asynchronous breathing towards recovery. Thus, it is important to monitor and quantify asynchronous breathing over every breath in an automated fashion, enabling the ability to overcome the limitations of model-based respiratory mechanics estimation during asynchronous breathing ventilation. METHODS An iterative airway pressure reconstruction (IPR) method is used to reconstruct asynchronous airway pressure waveforms to better match passive breathing airway waveforms using a single compartment model. The reconstructed pressure enables estimation of respiratory mechanics of airway pressure waveform essentially free from asynchrony. Reconstruction enables real-time breath-to-breath monitoring and quantification of the magnitude of the asynchrony (MAsyn). RESULTS AND DISCUSSION Over 100,000 breathing cycles from MV patients with known asynchronous breathing were analyzed. The IPR was able to reconstruct different types of asynchronous breathing. The resulting respiratory mechanics estimated using pressure reconstruction were more consistent with smaller interquartile range (IQR) compared to respiratory mechanics estimated using asynchronous pressure. Comparing reconstructed pressure with asynchronous pressure waveforms quantifies the magnitude of asynchronous breathing, which has a median value MAsyn for the entire dataset of 3.8%. CONCLUSION The iterative pressure reconstruction method is capable of identifying asynchronous breaths and improving respiratory mechanics estimation consistency compared to conventional model-based methods. It provides an opportunity to automate real-time quantification of asynchronous breathing frequency and magnitude that was previously limited to invasively method only.

Functional Outcomes 6 Months After Severe Traumatic Brain Injury Following Admission Into Intensive Care Unit: A Cohort Study in Two Tertiary Hospitals:

Severe traumatic brain injury (TBI) survivors show physical and functional improvements but continue to have cognitive and psychosocial problems throughout recovery. However, the functional outcome of severe TBI in Malaysia is unknown. The objective of this study is to measure the functional outcomes of severe TBI within 6 months post-injury. A cohort study was done on 33 severe TBI survivors. The Glasgow Outcome Scale–Extended (GOSE) was used in this study. The mean age of the participants was 31.79 years (range: 16-73 years). The logistic regression model was statistically significant, χ²(5, N = 33) = 29.09, p < .001. The length of stay (LOS) in incentive care unit (p = .049, odds ratio = 6.062) and duration on ventilator (p = .048, odds ratio = 0.083) were good predictors of the functional outcomes. Future research should focus on larger sample size of severe TBI in Malaysia.