Case series: two cases of life threatening dynamic airway obstruction from thyroid mass


We present 2 cases of dynamic airway obstruction with respiratory failure leading to cardiac arrest. Both have significant aetiology of cystic thyroid mass with sudden haemorrhagic changes leading to airway obstruction. We discuss the plausible pathophysiology leading to cardiopulmonary compromise where tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) play a significant role. We note that this is under recognised and can be present as a life-threatening event. Recognition of these pathophysiology process facilitate surgical management of thyroid obstructive airway disease.


Barriers to effective in-hospital resuscitation: lessons learned during implementation of a hospital-wide code system


Aims and objectives: To understand the barriers involved in effecting a hospital-wide code system and overcoming them during implementation.

Background: Improving survival after in-hospital cardiac arrest involves standardization of both defibrillation equipment and staff's abilities during codes.

Design: Observational descriptive study.

Methods: Observational study of the situation existing before implementation of an effective in-hospital resuscitation system and description of the implementation process. Descriptive statistics were used.

Results: Prior to intervention, defibrillators were unstandardized, misused and often inaccessible. Basic and advanced life support training was suboptimal and poorly overseen. Codes were attended by curious bystanders and inappropriate staff; there was lack of clarity regarding roles and key interventions. A standard defibrillator model was purchased and gradually deployed throughout the hospital; these were configured to meet the unique requirements of each department. Training was restructured. Standard operating procedures were created for all resuscitations while an oversight mechanism was installed. Code teams were created by taking departmental workloads and clinical skills into consideration. A nurse resuscitation coordinator was appointed per department and a hospital-wide culture was fostered where nurses were responsible for the quality of CPR. Major limiting issues such as distrust of device accuracy and safety, knowledge gaps and problems at the device-user interface were identified and bridged.

Conclusions: Creation of an effective in-hospital code system requires thorough research into the culture and requirements of various hospital departments. Multiple barriers must be overcome to set this process into motion.

Relevance to clinical practice: Implementation of change requires more than a declaration from supervisors; it requires deep understanding of the existing culture of different departments to take effective root. Awareness of these often unacknowledged issues combined with the willingness to confront and overcome them are keys to success.


Medication incompatibility in intravenous lines in a Paediatric Intensive Care Unit (PICU) of Indonesian hospital


Objectives: Currently, little is documented concerning the patterns of multiple concurrent medication use utilising single intravenous line. The in-line compatibility issues in Paediatric Intensive Care Units (PICUs) are not as well documented as in adult patients either. This study closely examined the combination of medications used concurrently in a PICU, recorded how medications were used, and then investigated the in-line potential compatibility.

Methods: This study was a mixed model designed first to identify retrospectively the patterns of multiple medication use at any single time of administration (STA). Secondly, a questionnaire was distributed to practitioners to elucidate their perceptions about incompatibility.

Results: From a single lumen peripheral line in-vitro simulation, it was observed that three infusions typically met in sequential Y-sites and had the potential to interact. The combinations identified were morphine+midazolam, midazolam+fentanyl+morphine, morphine+fentanyl+dobutamine, morphine+midazolam+ketamine, and midazolam+dobutamine+norepinephrine. Compatibility data covering simultaneous administration of three-or-more intravenous drugs was not found in 97.5% (n=120) of the cases. Most practitioners (92.9%) recognized incompatibility. Many (46.4%) said they observed >3-10 in-line incompatibilities in a month. Most nurses (78.5%) reported using the manufacturer as their reference source for compatibility data. Flushing with clear fluid between doses was the most used method to prevent incompatibility (45.5%).

Conclusions: It was a common practice to concurrently administer three or more medications: analgesics, sedatives, inotropes, and others, through the same port with major potential for incompatibility issues. Most of the literature is based on two drug comparisons with minimal information on using combinations of three or more. Most practitioners’ understanding of the implications of the terminology of “incompatibility not known or possible” for their patients appeared lacking.


Association of vitamin D plasma concentration with the severity of illness among children with sepsis treated in Pediatric Intensive Care Unit


Objective: To investigate whether vitamin D plasma concentration correlated with the severity of illness in sepsis children treated in a Pediatric Intensive Care Unit (PICU).

Design: This was a cross sectional study.

Settings: Pediatric Intensive Care Unit of Sanglah Hospital Denpasar, Bali, in May to November 2016.

Patients and participants: Samples were patients aged 28 days to 12 years who had sepsis or severe sepsis or septic shock and have been hospitalized in PICU. The subjects who met the inclusion criteria were divided into two groups based on the vitamin D status: normal and insufficient.

Intervention: The severity of illness of the patients in each group was measured using Pediatric Logistic Organ Dysfunction (PELOD) II and Pediatric Risk of Mortality (PRISM) III score. The demographic data, anthropometric status, and severity of the illness were taken from the medical records. The amount of sun exposure and patient nutritional intake were taken from questionnaires answered by the parents.

Results: A total of 48 patients were examined in this study. Bivariate analysis showed that vitamin D insufficiency was associated with a higher severity of sepsis based on the PRISM III (r=-0.44, p=0.006) and PELOD score (r=-0.5, p<0.001).

Conclusion: Vitamin D plasma concentration was negatively correlated with the illness severity in children with sepsis.


SARS 15 years on - My reflection on how to motivate your team to overcome the crisis?

Severe acute respiratory syndrome (SARS) was a new infectious disease that emerged in mid-November 2003 in Guangdong, southern China. By the time this global pandemic was declared contained on 5 July 2003 by WHO, it had afflicted 8090 patients in 29 countries.

No other disease had such a phenomenal impact on healthcare workers (HCWs), as they formed about 21% of SARS patients. In Vietnam, Canada and Singapore, the percentages of HCWs were 57%, 43% and 41%, respectively. The SARS crisis had become a medical plague.


Cardiac tamponade in acute necrotising pancreatitis


Objective: This case report highlights cardiac tamponade as a potentially significant complication of severe acute pancreatitis.

Settings: This patient was admitted to the Ng Teng Fong general hospital emergency department. He was subsequently admitted to the Intensive Care Unit (ICU) in the same hospital.

Patients: A 58-year-old male presented with severe acute gallstone pancreatitis with a Glasgow-Imrie criteria of 3. He was admitted for haemodynamic instability and acute respiratory distress syndrome (ARDS). The patient developed new-onset atrial fibrillation, persistent hypotension despite fluid resuscitation and increasing dependence on high inotropic support.

Investigations: A CT abdomen incidentally discovered an accumulation of pericardial fluid. Bedside echocardiography confirmed the presence of a large pericardial effusion consistent with cardiac tamponade. A CT scan revealed severe necrotising pancreatitis with a significant peripancreatic fluid collection.

Interventions: An emergency pericardiocentesis was performed and a pericardial drain was inserted. Eight hundreds ml of haemoserous pericardial fluid was drained over a period of 2 days. The patient’s haemodynamic status improved significantly after drainage of pericardial fluid.

Conclusion: Cardiac tamponade is one of the rare but clinically significant complications of severe acute pancreatitis and should be treated with a high index of suspicion in cases of acute pancreatitis with hypotension.