Placement of a double-lumen tube to achieve one lung ventilation is an aerosol-generating procedure. Performing it on a patient with COVID-19 will put healthcare workers at high risk of contracting the disease. We herein report a case of its use in a patient with traumatic diaphragmatic rupture, who was also suspected to have COVID-19. This article aims to highlight the issues, it presented and ways to address them as well as the perioperative impact of personal protective equipment.

Background Improving organ donation rates requires better detection of possible organ donors, which in turn necessitates identifying barriers preventing the identification of possible organ donors. The objectives of this study were to determine the actual rate of possible deceased organ donors among nonreferred cases and to identify barriers to their identification as possible donors. Methods This retrospective observational study used 6 months of data collected from two intensive care units (ICUs). Possible organ donors were defined as patients with a Glasgow Coma Scale score <5 and evidence of severe neurological damage. Barriers that led to the nonidentification of these patients as possible organ donors were also identified. Results Fifty-six of 819 patients admitted to the ICUs during the study period were detected as possible organ donors, representing a 6.83% possible organ donor detection rate. Nonclinical barriers to the identification of possible organ donors were found to be more significant than clinical barriers (55% vs. 45%, respectively). The most significant nonclinical barrier was an unknown reason, despite patients being medically suitable for deceased organ donation and fulfilling the criteria for possible organ donor classification. Unresolved sepsis was the main clinical barrier. Conclusions The significant rate of unreferred possible deceased organ donors found in this study reveals the need to increase awareness and knowledge among clinicians of the proper detection of possible donors at an early stage to avoid the loss of possible deceased organ donors, and thereby increase the deceased organ donation rate in Malaysian hospitals.

This is a case report on awake fibreoptic intubation for a patient with a deep neck space infection. Intubation in this group of patients is considered difficult. It is challenging to anaesthesiologists, emergency physicians and otorhinolaryngologists because there is no consensus for airway management in these patients. We present a 30-year-old gentleman with swelling over the right cheek, difficulty breathing and severe trismus. He had a history of toothache one month prior to admission. Upon clinical examination, there was a diffuse swelling over the right mandible. Other examinations were unremarkable. Provisional diagnosis of a right para-pharyngeal abscess was made secondary to a possible infected right lower 3 rd molar, with a differential diagnosis of a right parotid abscess with para-pharyngeal extension. Radiological assessment using computed tomography (CT) of the head and neck region showed an abscess over the right para-pharyngeal area, soft palate and right submandibular region. The narrowest part of the airway was at the region posterior to the soft palate, measuring approximately 1 cm. All staff and equipment were prepared for intubating a difficult airway. The patient was transferred to the control environment (operation theatre) for intubation. Awake nasal fibreoptic intubation (AFOI) was successfully performed for this patient using intravenous dexmedetomidine alone as the sedative.

BackgroundCoronavirus disease 2019 (COVID-19) emerged with a wide range of clinical presentations; Malaysia was not spared from its impact. This study describes the clinical characteristics of COVID-19 patients admitted to intensive care unit, their clinical course, management, and hospital outcomes.MethodsCOVIDICU-MY is a retrospective analysis of COVID-19 patients from 19 intensive care units (ICU) across Malaysia from 1 March 2020 to 31 May 2020. We collected epidemiological history, demographics, clinical comorbidities, laboratory investigations, respiratory and hemodynamic values, management, length of stay and survival status. We compared these variables between survival and non-survival groups.ResultsA total of 170 critically ill patients were included, with 77% above 50 years of age [median age 60, IQR (51–66)] and 75.3% male. Hypertension, diabetes mellitus, hyperlipidemia, chronic cardiac disease, and chronic kidney disease were most common among patients. A high Simplified Acute Physiology Score (SAPS) II score [median 45, IQR (34–49)] and Sequential Organ Failure Assessment (SOFA) score [median 8, IQR (6–11)] were associated with mortality. Patients were profoundly hypoxic with a median lowest PaO2/FiO2 ratio of 150 (IQR 99–220) at admission. 91 patients (53.5%) required intubation on their first day of admission, out of which 38 died (73.1% of the hospital non-survivors). Our sample had more patients with moderate Acute Respiratory Distress Syndrome (ARDS), 58 patients (43.9%), compared to severe ARDS, 33 patients (25%); with both ARDS classification groups contributing to 25 patients (54.4%) and 11 patients (23.9%) of the non-survival group, respectively. Cumulative fluid balance over 24 h was higher in the non-survival group with significant differences on Day 3 (1,953 vs. 622 ml, p &lt; 0.05) and Day 7 of ICU (3,485 vs. 830 ml, p &lt; 0.05). Patients with high serum creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and low lymphocyte count throughout the stay also had a higher risk of mortality. The hospital mortality rate was 30.6% in our sample.ConclusionWe report high mortality amongst critically ill patients in intensive care units in Malaysia, at 30.6%, during the March to May 2020 period. High admission SAPS II and SOFA, and severe hypoxemia and high cumulative fluid balance were associated with mortality. Higher creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and lymphopenia were observed in the non-survival group.

Eisenmenger syndrome (ES) is the most severe form of pulmonary arterial hypertension and is associated with congenital heart disease. ES itself is a challenging condition to manage, further compounded if the patient is critically ill and acutely decompensated. We share our experience of managing a critically ill adult patient with ES who presented with acute decompensation due to sepsis.