We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient’s hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient’s condition worsened, and she succumbed to death on day 7 of hospitalization.

Over the years, the number of pediatric patients undergoing surgeries are increasing steadily. The types of surgery vary between elective to emergency with involvement of multidisciplinary teams. The development of day care surgery unit is expanding where the patients will only come to the hospital on the day of surgery and discharge home after such as satisfactory parameters achieved, minimal to no pain, minimal to no bleeding from surgical site and able to tolerate fluids. Hospitalization and surgery could contribute to significant psychological disturbance to the children. These issues are not being addressed as children have difficulty in conveying their problems and fear. They do however express it through negative behavioral changes.

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A cervical spine injury is one of the leading causes of morbidity and mortality in clinical practice. The estimated worldwide spinal cord injury incidence is 40 to 80 new cases per million per year. This means that each year, between 250 000 and 500 000 people sustain a spinal cord injury [1]. The total numbers of trauma admission and blunt trauma resulting in cervical fracture increased between the years 2005 (38 009 cervical fracture [4.4% incidence]) and 2013 (55 700 cervical fracture [5.8% incidence]) [2].Airway management for cervical injury patients requires advanced skills and is associated with a high risk of morbidity. Awake fibreoptic (FO) in-

IntroductionBronchoscopy is a commonly used procedure in the context of aspiration in the Intensive Care Unit setting. Despite its ability to remove mucus plug and undigested gastric contents, aspiration of gastric content into the trachea is one of the most feared complications among anesthesiologist.DiscussionThe scenario is made worst if the aspiration causes acute hypoxemic respiratory failure immediately post intubation. However, in the event of desaturation, the quick decision to proceed with bronchoscopy is a challenging task to the anesthesiologist without knowing the causes.Case presentationWe present a case of a 12-year-old boy who had a difficult-to-ventilate scenario post transferring and immediately connected to ventilator in operation theatre (OT) from portable ventilator from the emergency department. She was successfully managed by bronchoscopy.ConclusionSpecial attention should be given to the difficult-to-ventilate scenario post intubation of traumatic brain injury patient prior to operation. Prompt diagnosis and bronchoscope-assisted removal of foreign body was found to be a successful to reduce morbidity and mortality.

IntroductionClosed suctioning is commonly used in the context of high-setting mechanical ventilation (MV), given its ability to prevent lung volume loss that otherwise accompanies open suctioning. However, closed suctioning systems (CSS) are not equivalent regarding components and capabilities, and thus this technique may be differentially effective to adequately clear patient secretions from an endotracheal tube (ETT), which is of paramount importance when the tube size makes the ETT particularly vulnerable to block by patient secretions.Case presentationA 25-year-old super morbidly obese female (body mass index = 55 kg/meter2) presented with worsening shortness of breath. For MV, pairing of a 6 mm (mm) diameter ETT to accommodate the patient's vocal cord edema, with a CSS not designed to maintain a clean catheter tip, precipitated ETT blockage and respiratory acidosis. Replacement of these devices with a 6.5 mm ETT and a CSS designed to keep the catheter tip clean resolved the complications. After use of the different ETT and CSS for approximately one week, the patient was discharged to home.DiscussionThe clean-tip catheter CSS enabled a more patent airway than its counterpart device that did not have this feature. Use of a clean-tip catheter CSS was an important care development for this patient, because this individual's super morbidly obese condition minimized tolerance for MV complications that would exacerbate her pre-existing tenuous respiratory health status.ConclusionSpecial attention should be given to the choices of ETT size and CSS to manage super morbidly obese patients who have a history of difficult airway access.

Background & Objective: Honey is one of the traditional drugs and has been widely used as a nutrient supplement for centuries. It is known to have antimicrobial, antioxidant and radical scavenging properties. We aimed to prove that natural honey can be added as a supplementary nutrient for its immunoprotective effects to the ventilated pneumonia patients in intensive care unit (ICU). Methodology: A total of 40 ventilated pneumonia patients were randomized to receive enteral feeding with honey (n = 20) or without honey (n = 20). A bolus of 20 g of honey was given every day for 5 days together with normal enteral nutrition. The baseline vital signs, ventilator settings, blood samples for C-reactive protein (CRP), white blood cell (WBC), interleukin-6 (IL-6), interleukin-10 (IL-10), immunoglobulin A (IgA) and blood sugar level were taken on the day of recruitment (Day 0) and subsequently on Day 3 and Day 6. Results: There were significant changes in IL-6 level over time in honey group with mean decrease of IL-6 from 265.1 pg/ml on Day 0 to 101.8 pg/ml on Day 6 (P < 0.001). There was no significant effect on CRP (P = 0.22), IL-10 (P = 0.548), IgA (P = 0.197), WBC count (P = 0.640) and blood sugar level between both groups (P > 0.05). Duration of antibiotic use between the two groups showed no statistically significant difference with P = 0.075 and length of ICU stay. Conclusion: Trigona honey showed the beneficial effect of immunonutrition to ventilated pneumonia patients in ICU by significantly decreasing the level of IL-6. Abbreviations: CAP: community acquired pneumonia; CRP: C-reactive protein; DHA: docosahexaenoic acid; HAC: hospital acquired pneumonia; ICU: intensive care unit; IL-6: interleukin-6; Ig-A: immunoglobulin A; NGT: Nasogastric tube; RBS: random blood sugar; VAP: ventilator associated pneumonia Citation: Zaini RHM, Omar SC, Binti Ismail IS, Wan Hassan WMN, Seevaunnamtum P, Che Hussin CM. A randomized study of an evaluation of Trigona honey as immunonutrition among ventilated pneumonia patients in intensive care unit. Anaesth. pain intensive care 2022;26(5):649-655; DOI: 10.35975/apic.v26i5.1990

Background: Total intravenous anaesthesia (TIVA) with a combination of target- controlled infusions (TCIs) of propofol and remifentanil has been advocated for a favourable neurosurgical outcome. Neurosurgical procedures often involve a prolonged duration and large cumulative infusion of propofol. This study compares the serial serum lipid profile, acid-base balance and lactate level of neurosurgical patients anaesthetised with TCIs of propofol at 2% versus 1%. Methods: A total of 74 patients who underwent an elective craniotomy under general anaesthesia were randomised into two groups: i) propofol 1% (n = 37) and ii) propofol 2% (n = 37). All patients were anaesthetised using TCIs of propofol and remifentanil. Serial lipid profiles (serum triglyceride [TG] and cholesterol levels) were taken at the baseline, upon cessation of propofol and at 2 h post-operation. The total dosage, volume used and syringe changes of both groups were also documented. Results: The total volume of propofol used was significantly lower in the 2% group than the 1% group (157.19 mL [SD = 77.14] versus 335.17 mL [SD = 174.27]; P = 0.005) and the frequency of syringe changes was also less in the 2% than the 1% group (2 [3] versus 6 [3]; P < 0.001). However, there were no significant differences between the two groups in terms of serial serum TG, cholesterol, the acid-base balance or the lactate level. There was also no significant correlation of lipid profile with cumulative dose or volume of propofol infused between the two groups. Conclusion: Both concentrations of propofol, 1% and 2%, were comparable in terms of the serial lipid profile, acid-base balance and lactate level during TIVA using TCIs for elective neurosurgery. The benefits of propofol at 2% were that a lower volume was used and there were fewer syringe changes, which could minimise anaesthesia interruption throughout surgery.