Ferric carboxymaltose (FCM) administration helps reduce transfusion requirements in the perioperative situation, which improves patient outcomes and reduces healthcare costs. However, there is ...increasing evidence of hypophosphataemia after FCM use. We aim to determine the incidence of hypophosphataemia after FCM administration and elucidate potential biochemical factors associated with the development of subsequent hypophosphataemia. A retrospective review of anonymised data of all FCM administrations in a single institution was conducted from August 2018 to August 2021. Each unique FCM dose administered was examined to assess its effect on Hb and serum phosphate levels within the subsequent 28 days from each FCM administration. Phosphate levels were repeatedly measured within the 28-day interval and the lowest phosphate level within that period was determined. Patients' serum phosphate levels within 28 days of FCM administration were compared against normal serum phosphate levels within 2 weeks before FCM administration. The odds ratios of various pre-FCM serum markers were calculated to elucidate potential biochemical predictors of post-FCM hypophosphataemia. In 3 years, a total of 1296 doses of FCM were administered to 1069 patients. The mean improvement in Hb was 2.45 g/dL (SD = 1.94) within 28 days of FCM administration, with the mean time taken to peak Hb levels being 6.3 days (SD = 8.63), which is earlier than expected, but was observed in this study and hence reported. The incidence of hypophosphataemia <0.8 mmol/L was 22.7% (n = 186), and <0.4 mmol/L was 1.6% (n = 9). This figure is lower than the numbers reported in previously published meta-analyses given that routine checks of serum phosphate levels were not conducted initially and hence could possibly be higher. The odds of developing hypophosphataemia (<0.8 mmol/L) were 27.7 (CI: 17.3-44.2, p < 0.0001) if baseline serum phosphate was less than 1 mmol/L. The odds of developing hypophosphataemia (<0.8 mmol/L) were 1.3 (CI: 1.08-1.59, p < 0.01) if the change in Hb levels observed after FCM administration were more than 4 g/dL. Hypophosphataemia after FCM administration is significant and FCM should be used by clinicians with caution.
Full text
Available for:
BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives
This case series would like to highlight hypophosphatemia related to ferric carboxymaltose and its adverse clinical consequences.
Background
Intravenous iron supplementation is a good ...alternative to oral iron replacement in iron deficiency anaemia due to its ability to correct iron deficit with minimal infusions without incurring the gastrointestinal side effects of oral iron replacement. Ferric carboxymaltose is one common formula for intravenous iron supplementation. However, an increasingly recognised adverse side‐effect of intravenous ferric carboxymaltose is hypophosphatemia. There has been increasing reports and studies highlighting hypophosphatemia related to intra‐venous iron therapy. Though initially thought to be transient and asymptomatic, recent studies have shown that persistent hypophosphatemia in iron therapy can result in debilitating disease including myopathy, fractures and osteomalacia.
Methods
A retrospective analysis of all patients who had ferric carboxymaltose was performed.
Results
We highlight 3 cases where hyposphatemia affected the clinical outcomes.
Conclusion
With the increased use of IV iron it is important to be aware of the high potential for hypophosphatemia secondary to ferric carboxymaltose.
Full text
Available for:
FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction:
Clinical bedside point-of-care ultrasonography (POCUS) is an important adjunct to history and physical examination. The objective of this pilot survey is to assess the level of ...exposure, perceptions, interest levels and possible barriers toward training of POCUS in internal medicine.
Methods:
In October 2015, all medical doctors who were working in the Singapore General Hospital Internal Medicine Department were invited to complete a hard-copy printed 27-question Likert-scale survey.
Results:
A total of 124 medical doctors participated in the survey (response rate 82.1%). The proportions of participants who have heard, witnessed, and performed POCUS were 65.6% (N = 82), 71.2% (N = 89) and 41.6% (N = 52), respectively. POCUS was rated highly on usefulness in the practice of internal medicine (M = 8.74; SD = 1.34). The top three POCUS skills that doctors would like to acquire would be (1) procedural guidance POCUS (70.8%); (2) point-of-care cardiac ultrasound (69%) and (3) lung ultrasound 58.4% (based on percentage ranked first through third). The sample mean of interest in undergoing further training in POCUS is 8.91 (SD = 1.27) (0 = not interested, 10 = very interested). The top three barriers identified were (1) lack of an ultrasound machine (M = 7.98 SD = 2.28); (2) cost of an ultrasound machine (M = 7.79 SD = 2.19) and (3) lack of a formal training curriculum (M = 7.25 SD = 2.08) (0 = not a barrier at all, 10 = severe barrier).
Conclusions:
There is a high level of exposure and interest in POCUS. Doctors perceived bedside POCUS as very useful in the practice of internal medicine. A lack of machine and formal curriculum impedes development of a training program. This pilot survey may serve as a basic needs assessment to an implementation of an internal medicine POCUS training curriculum.
Diabetic striatopathy is a rare condition associated with poorly controlled diabetes that can present as hyperkinetic movements. A 70-year-old Asian female was newly diagnosed with type 2 diabetes ...mellitus complicated by diabetic ketoacidosis when she presented with lethargy and confusion. Computed tomography and magnetic resonance imaging of the brain performed for the patient showed incidental isolated radiological features of diabetic striatopathy, even though she did not have any hyperkinetic movements. After intensive glycemic control, the patient paradoxically developed a delayed presentation of hemichorea two weeks later. Pathological findings in diabetic striatopathy suggest the contributing role of vascular microangiopathy, similar to the changes seen in proliferative diabetic retinopathy. In order to avoid precipitating hyperkinetic movements, a less intensive diabetic control could be considered for asymptomatic patients with isolated radiological features of diabetic striatopathy. This is especially important in patients at higher risk of the condition.
Introduction: There is worldwide concern over the psycho-emotional impact of COVID-19 on healthcare workers (HCWs). This study aimed to elicit HCWs' perceptions of the adequacy of protective measures ...in high-risk clinical areas and the factors associated with these perceptions.
Methods: This was a cross-sectional study conducted in April 2020. An anonymous electronic survey was sent via email to operating theatre (OT) and intensive care unit (ICU) staff of Sengkang General Hospital, Singapore.
Results: Of the 358 eligible participants, 292 (81.6%) responded to the survey. 93.2% of the participants felt that precautionary measures at work were sufficient and 94.9% acknowledged that adequate training was provided. More than 60% of the participants opined that their chances of contracting COVID-19 were moderate to high. Female gender, nursing occupation and duration of service <10 years were significantly associated with increased fear of contracting COVID-19, less control over occupational exposure and lower perceived need to care for COVID-19 patients. Having young children at home did not significantly affect these perceptions. The most important ICU precautions were availability of personal protective equipment outside the rooms of COVID-19 positive patients (95.3%) and having visitor restrictions (95.3%). The most important OT measures were having a dedicated OT for COVID-19 positive patients (91.2%) and having simulation as part of protocol familiarisation (91.7%).
Conclusion: Overall, there was high confidence in the adequacy of COVID-19 protective measures to prevent healthcare transmission in Singapore. The pandemic had a lower degree of psycho-emotional impact on HCWs here as compared to other countries.
The coronavirus disease 2019 outbreak has been designated a public-health emergency in major cities around the globe. Major health-care institutions are scrambling to implement effective infection ...control measures to ensure the safety of patients and visitors while minimising disruptions to the provision of quality health care. We describe the measures taken by the nuclear medicine units in the major health-care institutions within Singapore to ensure optimal delivery of care to our paediatric patients and their caregivers.
Point-of-care ultrasound is increasingly important in the management of acute medical emergencies. An elderly man was brought to the emergency department after 2 days of fever and urinary retention. ...He was drowsy and had peri-arrest arrhythmia. He was hypoperfused peripherally with a systolic blood pressure of 45 mmHg and so was managed as for septic shock with no obvious aetiology. Chest and abdominal physical examinations were unremarkable. The source of sepsis was unclear. A point-of-care abdominal ultrasound was performed by the reviewing internist which detected a pneumoperitoneum, leading to a change in diagnosis to a perforated viscus which was confirmed later by a CT of the abdomen and pelvis.
Pneumoperitoneum leading to septic shock is a medical emergency, but diagnosis is frequently delayed as the physical examination and chest and abdominal x-rays may fail to detect the condition in the critically ill patient, leading to delayed medical and surgical intervention.There is a role for point-of-care abdominal ultrasound for the early diagnosis of pneumoperitoneum with the air reverberation artefact.Point-of-care ultrasound of the abdomen to identify intra-abdominal air is an important physical examination adjunct in undifferentiated septic shock and should be incorporated into the routine care of patients and included in the acute medicine training syllabus.
Point-of-care bedside lung ultrasound is a diagnostic adjunct in the management of respiratory diseases. We describe the clinical progress and lung ultrasound findings of a Singaporean COVID-19 ...intensive care unit patient who was diagnosed with COVID-19 infection.
The clinical course of one COVID-19 patient managed in the intensive care unit was traced. The patient was diagnosed with COVID-19 virus infection and intubated after developing respiratory failure. Serial point-of-care bedside lung ultrasound was performed by the managing intensivist daily, and correlated with the clinical progress and chest X-ray imaging done for the patient.
The patient exhibited lung ultrasound findings consistent with that described for viral pneumonias. This included numerous B-lines and subpleural consolidations with disrupted pleural lines distributed symmetrically, predominantly in bilateral upper BLUE points, and lower BLUE points bilaterally. Coalescing B-lines leading on to the development of bilateral “white lung” were associated with worsening acute respiratory distress syndrome. An increased density or reduction of the B-lines was associated with clinical improvement or deterioration, respectively.
Trained clinicians, who are familiar with point-of-care lung ultrasonography, may consider point-of-care bedside ultrasound as an important adjunct to history and physical examination for the diagnosis and management of COVID-19 when advanced imaging is not available because of logistical reasons or infectious control. This applies in particular to cases where resources are limited, and patient transfers to facilities offering such services may prove hazardous.
Arterial and venous thrombosis are reported to be common in critically ill COVID-19 patients.
This is a national multicenter retrospective observational study involving all consecutive adult COVID-19 ...patients who required intensive care units (ICU) admission between 23 January 2020 and 30 April 2020 in Singapore. One hundred eleven patients were included and the venous and arterial thrombotic rates in ICU were 1.8% (n = 2) and 9.9% (n = 11), respectively. Major bleeding rate was 14.8% (n = 16).
Critically ill COVID-19 patients in Singapore have lower venous thromboembolism but higher arterial thrombosis rates and bleeding manifestations than other reported cohorts.
Full text
Available for:
IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
We aim to report a case of chest wall rigidity induced by high-dose fentanyl infusion sedation and analgesia in the intensive care unit (ICU) for management of pneumonia and asthma. The patient is an ...80-year-old woman, who presented to the hospital with complaints of fever and productive cough with yellowish expectoration of 2 days duration. She also had lethargy over the same time period and had sick contacts in the form of two daughters who both had recently recovered from a “flu-like” illness. She was known to have bronchial asthma treated with seretide 25/250 two puffs ON + PO monteleukast 10 mg ON, hypertension treated with PO losartan 50 mg BD, type 2 diabetes mellitus controlled with PO linagliptin 5 mg OM and a previous right thalamic ischemic stroke 5 years ago for which she was on PO clopidogrel 75 mg OM and PO simvastatin. She developed severe ventilator desynchrony characterized by dramatic sudden onset of severe hypercarbia, severely decreased pulmonary compliance and episodic breath holding. She was empirically treated for asthma exacerbation and treated with steroids, bronchodilators and manual ventilation but despite doing so during this episode the patient failed to respond. The patient was clinically evaluated and dynamic hyperinflation was excluded as a cause of the respiratory failure. There was no evidence of pneumothorax and worsening pneumonia. Considerations of insufficient sedation and analgesia led to deepening sedation and analgesia without good response. Ventilation was dramatically improved after small doses of neuromuscular relaxation. This cycle was repeated many times. The patient was kept on high-dose propofol and fentanyl, but there were repeated cycles of sudden persistent severe hypercarbia, severely decreased pulmonary compliance and episodic breath holding. Eventually a suspicion of fentanyl-induced chest wall rigidity was made after excluding causes of airway resistance and reduction in pulmonary compliance. Gradual reduction in fentanyl infusion was associated with a reduction of episodes of reduced lung compliance and improvement in ventilation. Fentanyl is often used for analgesia and sedation in the ICU. It has a good side effect profile but it is not without harm. High doses of fentanyl can lead to dramatic worsening of respiratory mechanics that may be life threatening. Fentanyl-induced chest wall rigidity is an important side effect that needs to be considered in the differential diagnosis of respiratory failure in the ICU.
PDF
