Background There is limited evidence to guide interventions that promote cost-effectiveness in ad... more Background There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. Methods A three-round modified online Delphi process, using a web-based platform sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilised a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. T...
Background Stevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the... more Background Stevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the skin and haemorrhagic erosions of mucous membranes. This report describes air-leak syndrome and obstructive uropathy occurring simultaneously in a teenage patient affected by SJS. Case presentation A 17-year-old Malay female with SJS suffered from bilateral pneumothoraces, pneumomediastinum, and obstructive uropathy as early complications of her disease. She required intubation, chest tube insertion, and bilateral ureteric stenting as part of her intensive care management. These extra-cutaneous complications of renal and pulmonary systems were likely secondary to widespread epithelial detachment. Conclusion Despite paucity of cases in adult literature, post-renal causes for acute kidney injury must be considered in SJS, especially in the setting of gross haematuria. Bedside point-of-care ultrasonography may be a useful tool for excluding obstructive uropathy. Pneumothorax is a rare but ...
Background Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in ... more Background Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction. Methods This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation. Results HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients...
Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this ... more Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period. Methods We conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions. Outcomes The rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Com...
Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acu... more Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO2/FIO2 [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO2/FIO2 (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients. Materials and methods This single centre 2-year retrospective study included ARF patients of...
Annals of the Academy of Medicine, Singapore, 2021
Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients r... more Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed postextubation HFNC. Methods: We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. Results: Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke w...
Annals of the Academy of Medicine, Singapore, 2021
Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mo... more Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed. Results: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile range [IQR] 67–75 versus median 61 years, IQR 52–66; P<0.01), and required a longer duration of ventilation (26 days, IQR 12–27 vs 8 days, IQR 5–15; P<0.01) and intensive care unit support (26 days, IQR 11–30 vs ...
Insertion of central venous catheters (CVCs) via the Seldinger technique is a routine procedure t... more Insertion of central venous catheters (CVCs) via the Seldinger technique is a routine procedure that is frequently performed in the intensive care unit (ICU) with few complications. Guidewire ensnarement is a serious complication, however, that can occur during ‘blind’ insertion in patients with inferior vena cava (IVC) filters. In this letter, we report a case of guidewire ensnarement during placement of a peripherally inserted central catheter (PICC) in order to raise awareness of this rare but avoidable complication and to discuss strategies for prevention. Written consent was obtained from the patient for publication of this report. A 48-year-old man was admitted to the ICU with subdural haemorrhage after receiving subcutaneous enoxaparin for lower limb deep vein thrombosis. Anticoagulation was stopped, and a retrievable Celect Platinum IVC filter (Cook Medical, Bloomington, IN, USA) was deployed infrarenally by an interventional radiologist. Eight days later, bedside PICC insertion with the XcelaR 5Fr 55 cm PICC kit (Navilyst Medical, Marlborough, MA, USA) was performed in the ICU. An 0.018-inch 145 cm hydrophilic floppy straight-tip guidewire was introduced into the right basilic vein under real-time ultrasound. The first attempt at guidewire cannulation was unsuccessful and resulted in mild curved deformation (<30 ) of the guidewire tip. The same guidewire was successfully introduced on the second attempt with no resistance followed by catheterisation with an over-the-wire technique. Attempts at guidewire withdrawal, however, were met with stiff resistance midway, and the procedure was aborted. The operator was still able to retrieve the guidewire in its entirety by withdrawing the PICC and guidewire en bloc, although the guidewire tip became unravelled in the process. A chest radiograph subsequently showed that the IVC filter had migrated into the right brachiocephalic vein and that one of the struts had become deformed (Figure 1). Interventional radiologists and vascular surgeons were consulted, and the IVC filter was successfully retrieved via an endovascular approach. Use of IVC filters is increasing. So, proceduralists should routinely review their patients’ medical history for the presence of intravascular devices prior to CVC insertion. Although bedside placement of a PICC without fluoroscopy can be routinely performed with success rates exceeding 90%, it is advisable that the procedure be performed under fluoroscopy in patients with an IVC filter. Should fluoroscopy be unavailable, operators are advised to utilise only the minimum length of guidewire necessary. Most guidewires are often longer than needed for optimal placement, and operators should pay close attention to the length markings on the guidewire. In general, the guidewire should not be advanced beyond 25 cm using the right jugular or femoral approach. Additionally, pre-procedure plain radiography can be performed to estimate the distance from needle entry site to the IVC filter. All reported
BACKGROUND Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensi... more BACKGROUND Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature. OBJECTIVES The objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC. METHODS A retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data. RESULTS One hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO2), higher partial pressure of oxygen to FiO2 ratio, and higher oxygen saturation to FiO2 ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO2 to improve oxygen saturations and noninvasive ventilation for rescue. CONCLUSIONS Among the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2012
To determine the impact on call characteristics and patient outcomes since the implementation of ... more To determine the impact on call characteristics and patient outcomes since the implementation of a two-tiered rapid-response system along with new observation charts and calling criteria. A retrospective before-and-after study in an Australian tertiary referral hospital. Consecutive adult patients (_18 years), who had a rapid-response call between June and October 2009 ("before") and between June and October 2010 ("after"). Incidence of "serious adverse events" (cardiac arrests, unexpected deaths, and unplanned intensive care unit/high-dependency unit [HDU] admissions); subsequent illness severity and ICU/HDU and hospital mortality and length of stay; episodes of repeat calls for the same patient, time since admission and treatment limitation/ not-for-resuscitation order profiles. Statistically significant increase in number of rapid response calls from 14.3 to 21.2 per 1000 hospital admissions before and after, respectively (P < 0.001); this was ass...
Background There is limited evidence to guide interventions that promote cost-effectiveness in ad... more Background There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources. Methods A three-round modified online Delphi process, using a web-based platform sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilised a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. T...
Background Stevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the... more Background Stevens-Johnson Syndrome (SJS) is an acute mucocutaneous eruption with blisters of the skin and haemorrhagic erosions of mucous membranes. This report describes air-leak syndrome and obstructive uropathy occurring simultaneously in a teenage patient affected by SJS. Case presentation A 17-year-old Malay female with SJS suffered from bilateral pneumothoraces, pneumomediastinum, and obstructive uropathy as early complications of her disease. She required intubation, chest tube insertion, and bilateral ureteric stenting as part of her intensive care management. These extra-cutaneous complications of renal and pulmonary systems were likely secondary to widespread epithelial detachment. Conclusion Despite paucity of cases in adult literature, post-renal causes for acute kidney injury must be considered in SJS, especially in the setting of gross haematuria. Bedside point-of-care ultrasonography may be a useful tool for excluding obstructive uropathy. Pneumothorax is a rare but ...
Background Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in ... more Background Delaying intubation in patients who fail high-flow nasal cannula (HFNC) may result in increased mortality. The ROX index has been validated to predict HFNC failure among pneumonia patients with acute hypoxemic respiratory failure (AHRF), but little information is available for non-pneumonia causes. In this study, we validate the ROX index among AHRF patients due to both pneumonia or non-pneumonia causes, focusing on early prediction. Methods This was a retrospective observational study in eight Singapore intensive care units from 1 January 2015 to 30 September 2017. All patients >18 years who were treated with HFNC for AHRF were eligible and recruited. Clinical parameters and arterial blood gas values at HFNC initiation and one hour were recorded. HFNC failure was defined as requiring intubation post-HFNC initiation. Results HFNC was used in 483 patients with 185 (38.3%) failing HFNC. Among pneumonia patients, the ROX index was most discriminatory in pneumonia patients...
Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this ... more Background COVID-19 pandemic has resulted in significant strain on healthcare resources and this requires diligent resource re-allocation. We aim to describe the incidence and outcomes of in-hospital cardiac arrest (IHCA) during this period as compared to non-pandemic period. Methods We conducted a retrospective study in a tertiary care hospital in Singapore. The study compared the incidence and outcomes of code blue activations over a 3-month period from March to May 2020 (COVID-19 period) with the same months in 2019 (pre-COVID-19 period). The primary outcome of the study was the rate of survival to hospital discharge for IHCA. The secondary outcomes included incidence of all code blue activation per 1000 hospital admissions, incidence of IHCA per 1000 hospital admissions. Outcomes The rate of survival to hospital discharge for IHCA was 5.88% in the COVID-19 period as compared to 10.0% in the pre-COVID-19 period [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.26-1.95]. Com...
Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acu... more Background High flow nasal cannula (HFNC) is increasingly being used to support patients with acute respiratory failure (ARF) and to avoid need for intubation. However, almost one third of the patients do not respond and require escalation of respiratory support. Previously, ROX index (SpO2/FIO2 [SF] ratio/respiratory rate) has been validated among pneumonia patients to facilitate early recognition of patients likely to fail HFNC and therefore, benefit from timely interventions. However, it has been postulated that incorporation of PaO2/FIO2 (PF) ratio from arterial blood gas (ABG) analysis may better predict the outcome of HFNC compared to indices that utilizes SF ratio. Similarly, heart rate increase after HFNC therapy initiation has been found to be associated with HFNC failure. Therefore, we aimed to compare ROX index with a new modified index to predict HFNC outcomes among ARF patients. Materials and methods This single centre 2-year retrospective study included ARF patients of...
Annals of the Academy of Medicine, Singapore, 2021
Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients r... more Introduction: Despite adhering to criteria for extubation, up to 20% of intensive care patients require re-intubation, even with use of post-extubation high-flow nasal cannula (HFNC). This study aims to identify independent predictors and outcomes of extubation failure in patients who failed postextubation HFNC. Methods: We conducted a multicentre observational study involving 9 adult intensive care units (ICUs) across 5 public hospitals in Singapore. We included patients extubated to HFNC following spontaneous breathing trials. We compared patients who were successfully weaned off HFNC with those who failed HFNC (defined as re-intubation ≤7 days following extubation). Generalised additive logistic regression analysis was used to identify independent risk factors for failed HFNC. Results: Among 244 patients (mean age: 63.92±15.51 years, 65.2% male, median APACHE II score 23.55±7.35), 41 (16.8%) failed HFNC; hypoxia, hypercapnia and excessive secretions were primary reasons. Stroke w...
Annals of the Academy of Medicine, Singapore, 2021
Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mo... more Introduction: Acute respiratory distress syndrome (ARDS) in COVID-19 is associated with a high mortality rate, though outcomes of the different lung compliance phenotypes are unclear. We aimed to measure lung compliance and examine other factors associated with mortality in COVID-19 patients with ARDS. Methods: Adult patients with COVID-19 ARDS who required invasive mechanical ventilation at 8 hospitals in Singapore were prospectively enrolled. Factors associated with both mortality and differences between high (<40mL/cm H2O) and low (<40mL/cm H2O) compliance were analysed. Results: A total of 102 patients with COVID-19 who required invasive mechanical ventilation were analysed; 15 (14.7%) did not survive. Non-survivors were older (median 70 years, interquartile range [IQR] 67–75 versus median 61 years, IQR 52–66; P<0.01), and required a longer duration of ventilation (26 days, IQR 12–27 vs 8 days, IQR 5–15; P<0.01) and intensive care unit support (26 days, IQR 11–30 vs ...
Insertion of central venous catheters (CVCs) via the Seldinger technique is a routine procedure t... more Insertion of central venous catheters (CVCs) via the Seldinger technique is a routine procedure that is frequently performed in the intensive care unit (ICU) with few complications. Guidewire ensnarement is a serious complication, however, that can occur during ‘blind’ insertion in patients with inferior vena cava (IVC) filters. In this letter, we report a case of guidewire ensnarement during placement of a peripherally inserted central catheter (PICC) in order to raise awareness of this rare but avoidable complication and to discuss strategies for prevention. Written consent was obtained from the patient for publication of this report. A 48-year-old man was admitted to the ICU with subdural haemorrhage after receiving subcutaneous enoxaparin for lower limb deep vein thrombosis. Anticoagulation was stopped, and a retrievable Celect Platinum IVC filter (Cook Medical, Bloomington, IN, USA) was deployed infrarenally by an interventional radiologist. Eight days later, bedside PICC insertion with the XcelaR 5Fr 55 cm PICC kit (Navilyst Medical, Marlborough, MA, USA) was performed in the ICU. An 0.018-inch 145 cm hydrophilic floppy straight-tip guidewire was introduced into the right basilic vein under real-time ultrasound. The first attempt at guidewire cannulation was unsuccessful and resulted in mild curved deformation (<30 ) of the guidewire tip. The same guidewire was successfully introduced on the second attempt with no resistance followed by catheterisation with an over-the-wire technique. Attempts at guidewire withdrawal, however, were met with stiff resistance midway, and the procedure was aborted. The operator was still able to retrieve the guidewire in its entirety by withdrawing the PICC and guidewire en bloc, although the guidewire tip became unravelled in the process. A chest radiograph subsequently showed that the IVC filter had migrated into the right brachiocephalic vein and that one of the struts had become deformed (Figure 1). Interventional radiologists and vascular surgeons were consulted, and the IVC filter was successfully retrieved via an endovascular approach. Use of IVC filters is increasing. So, proceduralists should routinely review their patients’ medical history for the presence of intravascular devices prior to CVC insertion. Although bedside placement of a PICC without fluoroscopy can be routinely performed with success rates exceeding 90%, it is advisable that the procedure be performed under fluoroscopy in patients with an IVC filter. Should fluoroscopy be unavailable, operators are advised to utilise only the minimum length of guidewire necessary. Most guidewires are often longer than needed for optimal placement, and operators should pay close attention to the length markings on the guidewire. In general, the guidewire should not be advanced beyond 25 cm using the right jugular or femoral approach. Additionally, pre-procedure plain radiography can be performed to estimate the distance from needle entry site to the IVC filter. All reported
BACKGROUND Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensi... more BACKGROUND Use of high-flow nasal cannula (HFNC) has become a regular intervention in the intensive care units especially in patients coming in with hypoxaemic respiratory failure. Clinical practices may differ from published literature. OBJECTIVES The objective of this study was to determine the clinical practices of physicians and respiratory therapists (RTs) on the use of HFNC. METHODS A retrospective observational study looking at medical records on HFNC usage from January 2015 to September 2017 was performed and was followed by a series of questions related to HFNC practices. The survey involved physicians and RTs in intensive care units from multiple centres in Singapore from January to April 2018. Indications and thresholds for HFNC usage with titration and weaning practices were compared with the retrospective observational study data. RESULTS One hundred twenty-three recipients (69.9%) responded to the survey and reported postextubation (87.8%), pneumonia in nonimmunocompromised (65.9%), and pneumonia in immunocompromised (61.8%) patients as the top three indications for HFNC. Of all, 39.8% of respondents wanted to use HFNC for palliative intent. Similar practices were observed in the retrospective study with the large cohort of 63% patients (483 of the total 768 patients) where HFNC was used for acute hypoxaemic respiratory failure and 274 (35.7%) patients to facilitate extubation. The survey suggested that respondents would initiate HFNC at a lower fraction of inspired oxygen (FiO2), higher partial pressure of oxygen to FiO2 ratio, and higher oxygen saturation to FiO2 ratio for nonpneumonia patients than patients with pneumonia. RTs were less likely to start HFNC for patients suffering from pneumonia and interstitial lung disease than physicians. RTs also preferred adjustment of FiO2 to improve oxygen saturations and noninvasive ventilation for rescue. CONCLUSIONS Among the different intensive care units surveyed, the indications and thresholds for the initiation of HFNC differed in the clinical practices of physicians and RTs.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2012
To determine the impact on call characteristics and patient outcomes since the implementation of ... more To determine the impact on call characteristics and patient outcomes since the implementation of a two-tiered rapid-response system along with new observation charts and calling criteria. A retrospective before-and-after study in an Australian tertiary referral hospital. Consecutive adult patients (_18 years), who had a rapid-response call between June and October 2009 ("before") and between June and October 2010 ("after"). Incidence of "serious adverse events" (cardiac arrests, unexpected deaths, and unplanned intensive care unit/high-dependency unit [HDU] admissions); subsequent illness severity and ICU/HDU and hospital mortality and length of stay; episodes of repeat calls for the same patient, time since admission and treatment limitation/ not-for-resuscitation order profiles. Statistically significant increase in number of rapid response calls from 14.3 to 21.2 per 1000 hospital admissions before and after, respectively (P < 0.001); this was ass...
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