We remember with love and joy Mahmoud Elbarbary, MD, PhD, MSc, EDIC (1959-2017)

Mahmoud left us on May 8th after a brief illness while in Riyadh Saudi Arabia, but what he left behind was an amazing legacy of service.


Incidence of CAUTI in a new integrated ICU/HD in Singapore over 1 year


Hospital-acquired infection worldwide has been associated with significant mortality and morbidity and unfortunately catheter-associated urinary tract infection (CAUTI) is known to be one of the commonest hospital-acquired infections.

A retrospective study was done to determine the incidence of CAUTI in the Intensive Care Unit/High Dependency (ICU/HD) in Ng Teng Fong General Hospital (NTFGH) since it was opened from 1 July 2015 to 31 July 2016. NTFGH Intensive Care Unit is an integrated ICU/HD unit that manages a combination of surgical, medical, trauma and cardiac patients. The inclusion criteria were patients catheterized and with urinary tract infections diagnosed in ICU/HD and also diagnosed with UTI within 48 hours of discharge from ICU/HD. The data was retrieved from hospital electronic database. The types of organisms and their resistant pattern to antibiotics were analysed.

A total of 3159 patients were admitted to the ICU/HD during this period. One hundred eighteen patients were diagnosed with urinary tract infections in general and out of this group 69 patients were noted to have CAUTI based on CDC criteria. The commonest organisms related to CAUTI were Escherichia coli and Klebsiella pneumoniae. These two organisms showed a similar pattern of establishing resistance to all the first line antibiotics used and they were ampicillin, amoxicillin-clavulanic acid and cephalosporins. Though the usage of quinolones, sulfamethoxazole-trimethoprim and gentamicin were low, these organisms have also established resistance to these 3 antibiotics. Enterococcus fecalis was the next commonest organism and was often associated with the presentation of diarrhea. Other organisms including Pseudomonas, Proteus, Enterobacter, Morganella, Citrobacter, Burkholderia and Staphylococcus were sporadically reported.

The common risk factors for developing CAUTI noted were surgical elderly male patients with diabetes and a history of obstructive UTI.

A committee involving a team from ICU has been set to review the current indwelling urinary catheter bundle and rectify the problems and implement new measures to reduce the incidence of CAUTI.


A randomized pilot study of parenteral glutamine supplementation in severe sepsis


Purpose: Glutamine depletion can occur in critically ill patients and parenteral glutamine supplementation can have beneficial effects on critically ill patients by preserving gut barrier and improving immune function. We wanted to examine the effect of glutamine supplementation in a cohort of severe sepsis patients admitted to a hospital in South East Asia.

Design: A single center, randomized, doubleblinded, placebo-controlled, pilot study. The primary outcome was 28-day mortality. Secondary outcomes were ICU length of stay (LOS), hospital LOS, duration of mechanical ventilation and occurrence of new infections. Disease severity on admission was assessed by Sequential Organ Failure Assessment (SOFA) score.

Setting: Medical intensive care unit (MICU) of Changi General Hospital, which is a 1000-bedded teaching hospital in Singapore.

Patients and participants: Patients admitted to the MICU for severe sepsis with ≥2-organ dysfunction.

Interventions: In the intervention arm, intravenous glutamine was given for 5 days at a dose of 0.5 g/kg body weight/day. The placebo was normal saline.

Measurements and results: Thirty-nine patients were randomized to receive glutamine (n=19) or placebo (n=20). The glutamine group exhibited milder disease severity than placebo (median SOFA score 8 vs 11, p=0.038). There was no overall difference in 28-day mortality between the glutamine and placebo (42% vs 15%, p=0.06). When adjusted for disease severity, the glutamine arm had 5.6 times higher death rates (95% CI 1.1-30.2, p=0.044). The glutamine group had lower incidence of new infections (0% vs 30%, p=0.02). There was no difference in ICU LOS, hospital LOS and the duration of mechanical ventilation.

Conclusions: Parenteral glutamine may increase mortality risk in ICU patients with severe sepsis while reducing the risk of new infections.


A comparison of NSS vs balanced salt solution as a fluid resuscitation and impact of fluid balance on clinical outcomes in pediatric septic shock


Septic shock is a common condition affecting children worldwide. Initial resuscitation with crystalloid fluid is the first step in treatment of septic shock. However, there is increasing concern about side effects of using normal saline. Our objective was to compare the effectiveness of balanced salt solution vs 0.9% normal saline solution (NSS) on decreasing morbidity and mortality in pediatric septic shock. This was a prospective observational study enrolled septic children aged 1-15 years treated at the Department of Pediatrics, King Chulalongkorn Memorial Hospital. They were given fluids resuscitation according to Surviving Sepsis Campaign (SSC) guidelines. Thirty-five sepsis children were enrolled, 20 received normal saline as first line fluid resuscitation and 15 received balanced salt solution (Ringer lactate solution [RLS]) as first line fluid resuscitation. Baseline characteristic of both groups were similar. RLS group received significantly less fluid resuscitation at 24 and 48 hours compared to NSS group (134.3±42.9 vs 171.3±49.5; p=0.02, 236.9±75.7 vs 313.1±115.3; p=0.03). Moreover, RLS group had significantly less metabolic acidosis and better base excess at 6 hours and 24 hours compared to NSS group (2.5±4.1 vs -3.7±4.1; p<0.001, 3.4±3.2 vs -1.2±3.9; p=0.03). There was no statistically significant difference in mortality between two groups (15% [n=3] NSS, 6.7% [n=1] RLS).

Conclusion: Using balanced salt solution for resuscitation decreased metabolic acidosis and tended to decrease fluid intake and fluid accumulation.


A 20-year-old woman with spinal cord injury without radiological abnormalities (SCIWORA)


Spinal cord injury without radiological abnormalities (SCIWORA) has been defined as a direct trauma to the spinal cord, with no radiological or tomographic abnormalities, although there is a deficit, whether motor, sensory or both. To establish the final diagnosis, shock, obstetrical complications, penetrating trauma to the spine and congenital malformations should be excluded.

Authors: Omar Alberto Venegas Gurrola, Omar Uriel Sánchez Alba, María Isabel Solís Gamboa, Goretti Monserrat Rodríguez Delgado

Factors contributing to the accuracy of initial screening values measured by noninvasive spectrophotometric hemoglobin monitoring in an Emergency Department


Objective: Spectrophotometric hemoglobin (SpHb) monitoring is a new noninvasive technology for measuring hemoglobin (Hb). However, few studies have assessed the usefulness of the initial screening SpHb values, especially when measured in an Emergency Department. In this study, we examined the correlation between the initial screening SpHb values and laboratory-measured hemoglobin (Hb) concentrations.

Design: This was a retrospective, single center study.

Setting: Emergency Department in a University hospital.

Patients: 105 cases between February and July 2016.

Interventions: The correlation between SpHb and Hb was determined in univariate analysis. Multiple regression analysis was then performed with ΔHb (defined as the absolute difference between SpHb and Hb [|SpHb-Hb|]) as the dependent variable to identify factors associated with reduced accuracy of SpHb.

Results: The initial screening SpHb value was only moderately correlated with Hb in univariate analysis (r=0.736, p<0.001). In multiple regression analysis, male sex and diastolic blood pressure were significantly associated with ΔHb (p=0.003 and p=0.022, respectively).

Conclusions: The initial screening SpHb value was only moderately correlated with Hb. SpHb might affected by patient factors, including male sex and diastolic blood pressure.


Portal venous gas entrapment secondary to mesenteric ischemia after withdrawal of intra-aortic balloon pump: A case report with a rare ultrasound image


After coronary artery bypass graft (CABG), mesenteric ischemia is a rare but dreadful complication with high mortality rates. Prophylactic use of intra-aortic balloon pump (IABP) is a common practice in patients with severe coronary artery disease awaiting CABG. During withdrawal of the IABP, there is a risk of dislodging atheromatous debris, thus causing peripheral and mesenteric emboli, which can cause mesenteric ischemia. Here we are reporting on a case where a patient had an IABP installed after a ST-elevation myocardial infarction (STEMI) while awaiting CABG surgery. After surgery, the IABP was eventually removed, but rising lactates led to further investigation. The abdominal computerized tomography (CT) scan showed extensive bowel pneumatosis and portal venous gas entrapment. The patient died despite aggressive non-surgical management. This case shows a fatal complication of IABP use in a high-risk patient undergoing CABG surgery and highlights the need for careful aorta and peripheral vascular assessment prior to IABP device insertion to avoid intestinal compromise.