Prevention of VAP - site visit of PYNEH ICU by Prof. David J Weber (USA), Central Infection Control Office and Cluster infection control team
2014 Nov 27 - Visit by Professor YU Kai Jiang, President of Critical Care Medicine Group of Chinese Medical Association
Date : 27 Nov 2014; Time: 0900-11:00, Venue: PYNEH ICU
From left to right: 楊毅教授, 康焰教授, 王春亭教授, 李建國教授, 于凱江教授, 殷榮華醫生, 陳恩發醫生, 劉俊穎醫生
Date: 25/9/2014; Time: 11:00am - 12:30pm; Venue: Lecture Room 3, 1/F, HKEC Training Center, PYNEH
Dr CW Lau and Ms HM So were interviewed by RTHK2 開卷樂 on HKSCCM book "生命現場"
Date: 29/5/2014, Time 16:00; Activity: Departmental Meeting
紫荆花悄悄爬上枝头，绽放着秋日的绚丽，那落英缤的花瓣为金色阳光勾勒出粉紫色的缤纷，衬托出香港特区独有的气质。9月，踏着紫荆的芬芳，我步入了香港东区尤德夫人那打素医院，开始了为期1月的“ ICU研修 ”生活。
Farewell Dinner for the promotion of Dr Helen Wu
Date 10 November 2011
Dr Helen Wu will leave PYNEH for promotion to Associate Consultant at Queen Elizabeth Hospital. Congratulations!
Date: 16 May 2012: Designer: Dr Arthur CW Lau, ICU, Pamela Youde Nethersole Eastern Hospital
NEW VERSION! These information pamphlets are routinely given out to patients or their families by the ICU of PYNEH, Hong Kong. Various generations of the pamphlets since 2006 are shown below. Click Read More.
Farewell Photos of Rotation MOs
Date: 31 December 2010
Dr Ellen OM CHENG, Dr Luke KY LEUNG, Dr Florence HY CHAN and Dr Patrick YH WONG finished their rotation to our ICU. We thank them for their significant contributions. Good luck!
Doctors doing round round using the Clinical Information System (CIS). From left to right: Dr LAM Sin Man Grace, Dr CHANG Li Li Lily, Dr CHAN Kin Wai, Dr WONG Kin Wa, Dr LI Ying Wah Andrew, Dr SHUM Hoi Ping
Doctors listening to clinical bedside teaching by Dr YAN Wing Wa (ICU Director) during ward round. From left to right: Dr CHANG Li Li Lily, Dr SHUM Hoi Ping, Dr KWAN Ming Chit Arthur, Dr WONG Kin Wa
6 July 1994
Venue: D10 ward, PYNEH
From left to right: Ms WONG Sui Woon, Ms NG Wai Fong, Dr Pamela LEUNG, Dr Wallace CHIU, Dr LAWMIN
Guests celebrating in the corridor outside Ward D10. The four guests on the left side are: Mr Law Chi Keung, Ms Mary Wan, Dr Ip Fu Keung, Dr LAU Chor Chiu.
First row, left to right: Dr LAWMIN, Ms WONG Sui Woon, Dr Wallace CHIU, Mr Fred Chan, Ms NG Wai Fong
Dr CHEUNG Chun Ming from the Department of Medicine with ICU nurses
Doctors from Department of Medicine, from left to right: Dr LAI Ting Kit, Dr LAU Chun Wing, Dr CHAN Kam Hon, Dr CHOW Chik Cheung.
Dr WN TANG, Dr Raymond YUNG, Ms PANG Mo Ching
Doctors from the Department of Anaesthesia, second left: Dr LAY, Dr ONSIONG, Dr LAWMIN
Dates: 24 June and 7 July 2010
Department photo was taken today (7 July 2010) with all staff.
PYNEH ICU Party
Date: 30 December 2009
Venue: 香港杏花村盛泰道100號杏花新城203舖 迎囍大酒樓
Click Read More to see more photos and videos.
Clinical Ward Rounds
We hold clinical rounds using the Clinical Information System at our conference room everyday at 0830. Bedside rounds of individual patients take place from 1030 - 1130, followed by daily Grand Rounds with seniors. Evening hand-over rounds start at 1600, and before midnight, on-call doctors also perform rounds of individual patients.
Testing a nerve stimulator in a patient paralysed by snake venom
Rounds with microbiologists take place every Tuesday.
Surgical Grand Rounds
Every Wednesday PM.
Radiology Rounds (joint round with Medical Respiratory Teams)
Every other Wednesday PM
Anteroom of the zone 1 isolation area
Other Clinical Duties
Associate Consultant and Medical Officers with accreditations of specialist status of medical specialtis also join specialty activities of the Department of Medicine, especially those of the Medical Respiratory Team and the Renal Team, e.g. outpatient clinics, grand rounds, radiology rounds. With the Resp Team, we have close working relationship and therefore some of us also join its administrative activities like regular business meetings.
Discussing how to read CXR
Every morning 0800 - 0830. Medical officers take turn to present one journal article every day.
Every Friday 1500 - 1600, by doctors or nurses.
We hold business meeting every morning among doctors, and with nurses and other staff every Thursday PM.
Discussion among staff during business meeting
Research and Development Meeting
Two times per month. To discuss about research projects and strategic development of the department.
Farewell to Dr WONG Kin Shing
Date: 29 June 2009
Isaiah 55:12 - You will go out in joy and be led forth in peace; the mountains and hills will burst into song before you, and all the trees of the field will clap their hands.
From left to right: Dr HP SHUM, Dr Arthur CW LAU, Dr WW YAN, Dr KS WONG, Dr Jackie TAM, Dr Kenny CHAN, Dr KW CHAN
Dr KS WONG will leave us for a missionary trip in Cambodia for four years. He has worked in our hospital for 16 years since 1993, latest as the Consultant and Head of our Renal Unit, Department of Medicine. Dr WONG and Dr WW YAN were classmates in the University of Hong Kong. Back in 1993 when Pamela Youde Nethersole Eastern Hospital was open, Dr Wong was the first senior medical office in charge of Dr Lau Chun Wing Arthur. He is going to help set up hemodialysis service in Cambodia, and will also be involved in missionary service.
Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury
Shum HP, Chan KC, Kwan MC, Yeung WT, Cheung WS, Yan WW
Poster presentation in 32nd International Symposium on Intensive Care and Emergency (2012)
Introduction: The optimal timing for initiation of renal replacement therapy (RRT) in septic acute kidney injury (AKI) remains controversial. The aim of this study is to investigate the impact of early versus late initiation of continuous RRT (CRRT), as defined using the simplified RIFLE classification, on organ dysfunction among patients with septic shock and AKI.
Methods: Patients were divided into early (sRIFLE Risk) or late (sRIFLE Injury or Failure) initiation of RRT. Patients with chronic kidney disease stage 5 or on dialysis were excluded.
Results: One hundred and twenty patients admitted within a 3.5-year period fulfilled inclusion criteria. Thirty-one (26%) underwent early, 89 (74%) had late CRRT. No significant difference was noted between the two groups with respect to change in total SOFA score/non-renal SOFA score in the first 24/48 hours after initiation of CRRT, vasopressor use, dialysis requirement and mortality (at 28 days, 3 months and 6 months). The change of nonrenal SOFA score 48 hours after CRRT correlated with the SOFA score at the start of CRRT (P = 0.034) and the APACHE IV risk of death (P = 0.000), but not the glomerular filtration rate (GFR) at the start of CRRT (P = 0.348). See Tables 1 and 2.
Conclusion: For septic shock with AKI, no significant difference in organ function and outcome was noted when the timing of initiation of CRRT was classified using sRIFLE criteria. Subsequent improvement of organ function correlated with initial SOFA and APACHE scores instead of the GFR (which determine sRIFLE class) on starting of CRRT. The use of more global assessment tools, such as the SOFA score, for stratification purposes on appropriate timing of CRRT warrants further investigation.
Extracorporeal membrane oxygenation (ECMO) in the treatment of severe pneumonia & ARDS
Presented at the HA convention 2011
Use of extracorporeal membrane oxygenation (ECMO) for treatment of respiratory failure in adults has received attention after the CESAR trial demonstrated a significant improvement in survival without severe disability in patients randomized to ECMO treatment compared to conventional ventilation (63% vs 47%; p=0.03). This technology has remained relatively new in Hong Kong until recently.
To describe the outcomes of patients in one ICU who received ECMO as salvage therapy for severe pneumonia and acute respiratory distress syndrome (ARDS) after failing conventional treatment.
Patients treated by ECMO for severe pneumonia in the Department of Intensive Care, PYNEH were retrieved by the Clinical Data Analysis and Reporting System (CDARS). Data was analyzed retrospectively.
From October 2009 to January 2011, 14 patients were treated by ECMO for severe pneumonia and ARDS: Influenza A (H1N1) 11 (78.6%), Metapneumovirus 1 (7.1%), Mycoplasma 1 (7.1%), unknown aetiology 1 (7.1%). The median (interquartile range; IQR) age was 42 (35-54). The median (IQR) APACHE II score and risk of death were 29 (18-33) and 0.67 (0.29-0.78). Six patients were referred from 2 public and 1 private hospitals. Two of them had desaturations despite high pressure and oxygen ventilation, and required cannulation at the referring hospitals and transferral on ECMO. All 14 patients survived and were discharged home after a median (IQR) ICU, acute general and convalescent stay of 16 (14-22), 28 (16-32) and 11 (0-22) days. The median (IQR) ECMO duration was 5 (4-6) days.
Objective: Results: 1. Concern and caring by ICU staff to patients = 72.9 2. Patient’s symptom management = 67.3 3. Concern and caring by ICU staff to patients’ families = 63.6 4. Nurses’ performance = 62.2 5. Doctors’ performance = 68.1 6. ICU atmosphere = 51.1 PART 2: FAMILY SATISFACTION WITH DECISION-MAKING AROUND CARE OF CRITICALLY ILL PATIENTS 1. Information needs = 58.0 2. Process of making decisions = 49.0 Conclusion: 2. Patients’ families were less satisfied with the information we provided (“frequency of communication with ICU doctors”, “ease of getting information” and “understanding of information”) and process of decision making (“being included and supported in the decision making process”, “has control over the care of family members”, “adequate time to have concerns addressed and questions answered”). 3. It is often assumed that paternalistic doctor-patient relationship is well accepted in Chinese society. This may no longer remain true in a modern metropolis like Hong Kong. 4. Families can be more actively involved in decision making on various treatment options. 5. Measures e.g. video show and pamphlets explaining general ICU care and procedures can be efficient ways to provide information to families in a busy ICU. Grace SM Lam, Arthur CW Lau. Prevention of ventilator-associated pneumonia (VAP) by novel endotracheal tube designs. Hong Kong Lung Foundation, Hong Kong Thoracic Society & ACCP (HK & Macau Chapter) Newsletter 2011 April, 32-35 Lam SM, Lau ACW. Alveolopleural or bronchopleural fistula – From the critical care physicians’ perspective. Hong Kong Lung Foundation, Hong Kong Thoracic Society & ACCP (HK & Macau Chapter) Newsletter 2009; 19(1): 22-24 Ernest NP Wong, Arthur CW Lau, Kenny KC Chan, HP Shum, Angus HY Lo, Anne KH Leung, WW Yan. Feasibility, cost-effectiveness and staff satisfaction of continuous hemofiltration using regional citrate anticoagulation and on-line prepared replacement solution for critically ill patients in the intensive care unit. Abstract, THE THIRTEENTH INTERNATIONAL CONFERENCE ON CONTINUOUS RENAL REPLACEMENT THERAPIES February 27- March 1, 2008 Hotel Del Coronado, San Diego CA Arthur C. W. LAU,1 Mary S. M. Ip,2 Christopher K. W. LAI,3 K. L. CHOO,4 K. S. TANG,5 Loretta Y. C. YAM,1 Moira CHAN-YEUNG2VARIABILITY OF THE PREVALENCE OF UNDIAGNOSED AIRFLOW OBSTRUCTION IN SMOKERS USING DIFFERENT DIAGNOSTIC CRITERIA. (APSR 2007)
ICU family satisfaction survey
Wu HL, Chan CS, Ho HC, Li C, Ma LH, So WY, Yan WW, Kwok N
Presented at the HA convention 2011
Providing professional care and establishing good rapport with patients is our mission. However, building a good relationship with patients’ family is equally important. This helps to relieve their anxiety and reduce potential complaints due to miscommunication.
This survey result can help to identify the strength and weakness concerning our care provided to patients and their families. The result can also help guiding us to prioritize the resources for improvement in the future.
The next-of-kin of patients admitted to Intensive Care Unit (ICU) of Pamela Youde Nethersole Eastern Hospital (PYNEH) within a 3 month period were contacted by phone and asked to complete a questionnaire: FS-ICU-24. A transformed score ranging from 0-100 will be given to each question/category. Higher score means better performance.
A total of 36 people were interviewed, with mean age 52.7 years old (range 22-88). 38.9% were male and 61.1% were female. The mean scores for each aspect are as follows:
PART 1: SATISFACTION WITH CARE
1. Patients’ next-of-kin were in general satisfied with the care provided by ICU to both patients and their families, especially the care provided to patients (72.9 vs 63.6).
Extracorporeal Life Support for Poisoning – A Case Report & Literature Review
Presented at the HKSCCM & HKACCN Annual Scientific Meeting 2009, Authors: Chan KC, Shum HP, Yan WW
With advancement of technology, there is a re-emerging interest of extracorporeal life support (ECLS) in very sick patients with reversible underlying problem, such as acute respiratory distress syndrome. Many poisonings are also very reversible, and ECLS has an additional part to play in enabling extracorporeal removal of toxins in haemodynamically unstable patients.
To review the literatures concerning the use of ECLS in supporting victims of poisonings and report our experience in the use of ECLS and high-volume haemodiafiltration (HVHDF) in a case of fatal paraquet poisoning.
Case History and Findings:
A young lady was admitted soon after ingestion of 21 grams of paraquat. Her vitals were stable on admission. Enteral charcoal, heamocharcoal perfusion, HVHDF and immuno-suppression were started. She developed respiratory failure in day 3. Veno-venous ECLS was started in attempt to minimize FiO2 and lung toxicity. We managed to keep the FiO2 at 0.21 for a week. HVHDF was continued for toxin removal. Unfortunately, she developed sepsis in the second week of ICU stay and she succumbed on day 14. There was only small amount of fibrosis in the post-mortum examination of the lungs. Search of PubMed yielded 23 case report or case series regarding use of veno-venous or veno-arterial ECLS for severe poisoning.
ECLS may have a role in supporting selected cases of severe poisoning with cardio-pulmonary failure.
Regional Citrate Anticoagulation in Predilution Continuous Venovenous Haemofiltration Using Prismocitrate 10/2 Solution
Shum HP, Chan KC, Yan WW Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China
Poster Presentation on APCN 2011
INTRODUCTION: Regional citrate anticoagulation (RCA) for continuous renal replacement therapy is associated with longer filter-life and less bleeding events. Complexity of the regimen is the major hurdle preventing its wide spread applications.
OBJECTIVE: To investigate the feasibility of a simple predilution continuous venovenous haemofiltration (CVVH) protocol, utilizing a commercially-prepared citrate-containing replacement solution (Prismocitrate 10/2) for RCA
METHODS: Six patients with sepsis and acute renal failure were evaluated. The Prismaflex system (Gambro-Hospal) was used for predilution CVVH (Figure 1). Prismocitrate 10/2, running at 2500ml/h, was the main predilution replacement. 8.4% sodium bicarbonate solution was infused at 50ml/h in the first 2 hours, and then at 30ml/h, via the ‘Heparin port’ of the circuit (pre-filter). 10% calcium gluconate was infused via a separate central venous catheter to achieve an ionized calcium (iCa) level of 1-1.2mmol/L. The fluid withdrawal rate was adjusted to achieve the desired fluid balance. The circuit was run for 72-hours, unless there was filter clotting or the patient did not require further CRRT.
RESULTS: Six sessions of predilution CVVH, with total treatment duration of 336 hours, were performed. The post-dilution equivalent ultrafiltration rate was 34.2±3.2ml/kg/h (mean±SD). There was no filter clotting in all sessions. Pre-filter and post-filter iCa were 0.249±0.02mmol/L and 0.265±0.04mmol/L respectively. Arterial iCa was maintained at 1.04±0.13mmol/L, with a 10% calcium gluconate infusion of 16.6±1.5ml/h. The total-calcium to iCa ratio was 2.25±0.13. No patient has a sodium level ≥150mmol/L, or metabolic alkalosis (pH≥7.5), or any evidence of citrate toxicity.
CONCLUSIONS: This predilution CVVH protocol with RCA is safe, effective and easy to implement.
Quality Improvement Program (QIP) on Pressure Ulcer Prevention and Management in Intensive Care Unit (ICU)
Lau Y Y1, 2, Lo W P1, 2, Kwok L P1, 2, Chang L F1, 2, Liu S K1, 2, Tam Y F1, 2, Yeung M W1, 2, Li S C1, 2, Wong H Y1, 2
Department of Intensive care1, Pamela Youde Nethersole Eastern Hsopital2
Poster Presentation on The 3rd HKEC Quality & Safety Seminar 2009/10 - Better Health for All: Mission, Passion and Action on 6 March 2010 (Saturday)
Pressure ulcer is common in a variety of health care setting. In critical care unit, patients are at particular risk of developing pressure ulcer. However, the presence of pressure ulcer may contribute to adverse health outcomes in turn to increase mortality in patients. Moreover, the incidence of pressure ulcer is one of the quality signs of health centres. It has also a significant impact on healthcare costs. National organization recommends that quality improvement should be done for prevention and management of pressure ulcer. Use information from quality improvement data to determine the need for education and policy changes. A quality improvement program was implemented in intensive care unit in the year of 2009.
Purposes of the project
The aim of this program was (1) to reduce the incidence of pressure ulcer in ICU. (2) to enhance the standard care of pressure ulcer among critically ill adult patients.
The Quality Improvement Program (QIP) consisted of an audit on standard care of pressure ulcer. After the audit had been completed, an in service training was done on the poor compliance area which including assessment, skin care and documentation of pressure ulcer. Finally, an audit was done again to evaluate the effective of the training. Outcome measures were categorized as (1) Incidence rate of pressure ulcer, (2) Compliance rate of standard care of pressure ulcer
An audit on standard care of pressure ulcer was done by the first quarter in 2009. Result found that three areas in poor compliance rate with 74% on daily assessment; 70% on skin care; 76% on documentation of the pressure ulcer. After that an in service training was provided to fifty-six nurses to enhance the daily assessment, skin care and documentation of pressure ulcer by the second and third quarter in 2009. In addition, a training program of incontinence skin care was provided to twelve health care workers. After the implementation of the in service training, the audit was taken place again in the fourth quarter in 2009. Result found that there is a significantly improvement of the standard care of pressure ulcer. Average compliance rate is 96%. Result also found that the three areas with poor compliance rate in first quarter also got improving with 94% on daily assessment; 91% on skin care; 93% on documentation of the pressure ulcer.
On the other hand, the incidence rate of pressure ulcer was also monitoring through out the year of 2009. Result found that incidence rate was 5.7% (n = 7) in the first quarter and 5.8% (n = 7) in the second quarter. After the in service training program, reduction of the incidence rate was noted with 0.7% (n = 1) in third quarter and 0.7% (n = 2) in fourth quarter.
Pressure ulcer is preventable although it is common in a variety of health care setting. A significant reduction in the incidence rate of pressure ulcers occurred as the result of the QIP. It is also benefit to enhance the standard care of pressure ulcer. Periodical implement it in a variety of health care setting is recommended in future.
PYNEH Intensive Care Unit (ICU) admission characteristics, patient’s outcomes and performance from 2007 to September 2009 (8. Clinical Audit and Effectiveness). Poster presentation in HKEC quality and safety seminar in 2009/10.
Authors: Shum HP, Yan WW
Objective: To report Intensive Care Unit (ICU) admission characteristics, patient’s outcomes and performance from 2007 to September 2009.
Design: Retrospective, cohort study of prospectively collected data on index patient admissions.
Setting: Pamela Youde Nethersole Eastern Hospital, Intensive Care Unit
Patients: All patients admitted to ICU from 1 Jan 2007 to 30 Sep 2009. Patient’s age less than 16 years old, ICU stay less than 4 hours or those with unclear hospital outcome were excluded.
Main results: Among 3324 patients admitted during the study period, 110 patients (3.3%) were excluded for analysis. The ICU admission rate increased gradually from 1135 in 2007 to 1337 in 2009 (projected). The ratio of elective versus emergency admission remained quite static at around 0.2. However, patients who had significant co-morbidities increase rapidly. Medical, surgical and neuro-surgical cases accounted for > 90% of ICU admission. The mean (+/- SD) ICU length of stay decreased from 4.9 7.6 days in 2007 to 3.9 5.8 days in 2009, which was similar to Hospital Authority overall ICU average. Although ICU nursing manpower decreased from 71.5 in 2007 to 66 in 2009, ICU mortality improved from 14.7% to 12.9%. The hospital mortality also decreased from 21% in 2007 to 20.2% in 2009. Despite a slight increase of readmission rate from 6.4% in 2007 to 7.6% in 2009, the APACHE (Acute Physiology and Chronic Health Evaluation) IV Standardized mortality ratio (SMR) decreased from 0.76 in 2007 to 0.71 in 2009 which was favourable when compared with other major ICUs in Hong Kong.
Conclusion: The mean ICU length of stay decreased by one day and mortality decreased by 1.8% in around 3-years time. The APACHE IV SMR also showed significant improvement over time. These achievements could be due to improvement of nursing care, implementation of computer information system to decrease potential medication errors and emphasis of continuous on-job training and educations.
Ms Lau Yuk Yin, Grace. Quality Improvement Program (QIP) on Pressure Ulcer Prevention and Management in Intensive Care Unit (ICU)
(Clinical Audit and Effectiveness). Abstract, HKEC 3rd Quality & Safety Seminar 09/10
PYNEH intensive care unit consultation pattern and patients’ outcomes
Shum HP 1, Chan KC 1, Lau CW 1, Chan KW 1, Yan WW 1; 1 Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
Poster presentation for Hospital Authority Convention 2009
Objective: To assess our ICU consultation pattern and determine factors associated with patients’ survival.
Design: Single-centre, prospective observational cohort study.
Setting: 20-beds medical-surgical intensive care unit (ICU) in a 1400-bed regional hospital.
Measurements and main results: The study lasted 9 months (Jan to Sept 2007). All patients were followed up till discharge or hospital death. 1346 consultations were included. 802 (59.6%) were male. Mean age was 65.7 ± 17.8 years. 402 (29.9%) occurred during weekday office hours (0800-1700), 586 (43.5%) at weekday non-office hours and 358 (26.6%) on weekends / Sundays/ public holidays. 900 (66.9%) were initiated for ICU support / opinion and 332 (24.7%) for post-operative care, 63 (4.7%) were trauma calls and 51 (3.8%) for resuscitation. 837 (62.2%) from general wards and 210 (15.6%) from Accident and Emergency Department. 647 (48.1%) from Medical Department, 386 (28.7%) from Surgical and 178 (13.2%) from Neurosurgical Department. 871 (64.7%) required intensive treatment or monitoring, 225 (16.7%) were considered “inappropriate” or “unnecessary” consultations because of low risk conditions or terminal / irreversible illness. 250 (18.6%) were those “borderline” cases with reduced likelihood of recovery. 858 (63.7%) consultations were admitted to ICU, 451 (33.5%) were rejected, 23 (1.7%) and 14 (1%) consultations were failed resuscitation and transferral to Cardiac Care Units or other hospitals. Hospital mortality was 27.3% (367 patients). 238 (52.7%) consultations rejected were considered too sick to benefit from ICU care (hospital mortality 62.2%) and 213 (47.2%) consultations were regarded too well to benefit from ICU care (hospital mortality 4.2%). Older age, rejection from ICU care, admission diagnosis, poorer ICU physician-predicted chance of long-term survival and higher Mortality Prediction Model II0 (MPMII0) predicted mortality were independent risk factors for hospital mortality (Table).
Conclusion: Among all factors independently associated hospital mortality, only “rejection from ICU care” was potentially modifiable. For those patients regarded too sick to benefit from ICU care, further investigation is needed to see whether ICU care could really provide potential survival benefit and quality of life if more of them are to be admitted.
Assessment of three hospital mortality prediction models in patients admitted to Pamela Youde Nethersole Eastern Hospital intensive care unit” – Free paper oral presentation at Annual Scientific Meeting of the Hong Kong Society of Critical Care Medicine and the Hong Kong Association of Critical Care Nurses 2009
Authors: Shum HP, Chan KC, Yan WW
Institution: Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong
Tel: 25956488, 25956111
Objective: To assess the validity of mortality prediction systems in patients admitted to our intensive care unit (ICU). We included Acute Physiology and Health Evaluation (APACHE) II, APACHE IV and Simplified Acute Physiology Score (SAPS) II in our evaluation.
Design: A single centre prospective observational cohort study
Setting: General ICU in a tertiary regional hospital
Patients: All patients admitted to ICU in 2008 with ICU stay more than 4 hours and age >16 years old
Methods: The data necessary for mortality prediction were collected prospectively via the Clinical Management System. Predicted and actual mortality rates, and standardized mortality ratio (SMR) were calculated. Discrimination was assessed using receiver operating characteristic (ROC) curves. Calibration was assessed using Hosmer Lemeshow goodness of fit C-statistic.
Results: A total of 1194 consecutive ICU admissions occurred in 2008, of which 1117 met inclusion criteria. The SMR for APACHE II, APACHE IV and SAPS II was 0.62, 0.78 and 0.48 respectively. Discrimination was best for APACHE IV (area under ROC curve = 0.862), followed by APACHE II (0.826) and SAPS II (0.812). However, the difference is not statistically significant. Calibration was inadequate for APACHE IV (C-statistic 22.35, p=0.004) and SAPS II (C-statistic 17.14, p=0.029).
Conclusion: APACHE IV predictions of hospital mortality have good discrimination as compared with other models but it had inadequate calibration. Difference of patient’s characteristics may be the reason and customization of model should be considered.
Outcomes of Patients Discharged from the Intensive Car Unit at Night Time
Authors: Leung YW, Shum HP, Chan KC, Lau CW, Yan WW
Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
Background and Objectives:
The demand for Intensive Care Unit (ICU) service is high and increasing. When the need for ICU bed arises during tight bed status, sometimes patients have to be discharged from ICU at nighttime. Overseas studies showed that night time discharge had higher mortality. This study tried to look for any adverse outcomes associated with night time discharge in the ICU of Pamela Youde Nethersole Eastern Hospital, Hong Kong.
A retrospective study of all admissions in 2008 to our ICU was carried out. Daytime was defined as "0700-1959", and nighttime "2000-0659". Nighttime discharge was not our routine workflow unless there was urgent need for an ICU bed.
1162 out of the 1,258 admissions in 2008 had complete data. 152 (13.1%) died during ICU stay. Remaining 1,010 admissions were included for final analysis. 65 (6.4%) of discharge episodes occurred at nighttime. Compared with daytime discharge, nightime discharge showed no statistical difference in age, parent specialty, underlying co-morbidity, ICU length of stay (LOS), hospital LOS, APACHE II /IV scores and APACHE II/ IV risk of death. Elective ICU admissions and immediate post-operative cases were less likely to be discharged at night time. For daytime and nighttime discharge respectively, the hospital (8.1% vs. 9.2%, p=0.759), 3-month (10.7% vs. 13.8%, p=0.429) and 6-month mortality (15.2% vs. 13.8%, p=0.762) was similar, and so were readmission rates (7.2% vs. 7.7%, p=0.845).
In our ICU, nigthtime discharge, compared with daytime discharge, was not associated with adverse outcomes in terms of hospital, 3-month and 6-month mortality. There was also no difference in the readmission rate.
Acute poisoning in an intensive care unit and their outcomes (HA Convention 2009)
Lam SM1, Lau ACW1, Yan WW1 1Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
Shum HP, Chan KKC, Lau ACW, Yan WW. PYNEH intensive care unit consultation pattern and patients' outcomes. HA Convention 2009.
Lam SM, Lau ACW, Yan WW. Acute poisoning in an intensive care unit and their outcomes. Hospital Authority Convention 2009 poster
Lam SM, Lau ACW, Yan WW. Medical thoracoscopy in the intensive care unit. Oral presentation at the Asian Intensive Care: Coming of Age Conference. Hong Kong 2009
Lam SM. What are the advantages and disadvantages of each aerosol delivery devices? Is there any benefit of one over another? Hong Kong Lung Foundation, Hong Kong Thoracic Society & ACCP (HK & Macau Chapter) Newsletter 2008; 18(2): 23-5
Henry C. Y. CHEUNG, Arthur C. W. Lau, Alfred Y. F. CHAN, H. P. SHUM, Grace S. M. LAM, Natalie Y. W. LEUNG, Angus H. Y. LO, Loletta K. Y. SO, W. W. YAN, Loretta Y. C. YAM CHARACTERISTICS AND OUTCOMES OF PULMONARY TUBERCULOSIS PATIENTS REQUIRING INTENSIVE CARE IN HONG KONG. (APSR 2007)
Shum HP, Chan KC, Yan WW. PYNEH ICU consultation pattern and performance. Poster presentation in HKEC quality and safety seminar (2007)
Shum HP, Chan CK, Lo SH, Mo KL; Wong KS. Late nephrologist referral of patients with advanced renal failure was associated with poorer short-term outcomes but no difference in 2-years morbidity and survival. Poster presentation in 11th Congress of the International Society of Peritoneal Dialysis (2006)
1. Concern and caring by ICU staff to patients = 72.9
2. Patient’s symptom management = 67.3
3. Concern and caring by ICU staff to patients’ families = 63.6
4. Nurses’ performance = 62.2
5. Doctors’ performance = 68.1
6. ICU atmosphere = 51.1
PART 2: FAMILY SATISFACTION WITH DECISION-MAKING AROUND CARE OF CRITICALLY ILL PATIENTS
1. Information needs = 58.0
2. Process of making decisions = 49.0
2. Patients’ families were less satisfied with the information we provided (“frequency of communication with ICU doctors”, “ease of getting information” and “understanding of information”) and process of decision making (“being included and supported in the decision making process”, “has control over the care of family members”, “adequate time to have concerns addressed and questions answered”).
3. It is often assumed that paternalistic doctor-patient relationship is well accepted in Chinese society. This may no longer remain true in a modern metropolis like Hong Kong.
4. Families can be more actively involved in decision making on various treatment options.
5. Measures e.g. video show and pamphlets explaining general ICU care and procedures can be efficient ways to provide information to families in a busy ICU.
Grace SM Lam, Arthur CW Lau. Prevention of ventilator-associated pneumonia (VAP) by novel endotracheal tube designs. Hong Kong Lung Foundation, Hong Kong Thoracic Society & ACCP (HK & Macau Chapter) Newsletter 2011 April, 32-35
Lam SM, Lau ACW. Alveolopleural or bronchopleural fistula – From the critical care physicians’ perspective. Hong Kong Lung Foundation, Hong Kong Thoracic Society & ACCP (HK & Macau Chapter) Newsletter 2009; 19(1): 22-24
Ernest NP Wong, Arthur CW Lau, Kenny KC Chan, HP Shum, Angus HY Lo, Anne KH Leung, WW Yan. Feasibility, cost-effectiveness and staff satisfaction of continuous hemofiltration using regional citrate anticoagulation and on-line prepared replacement solution for critically ill patients in the intensive care unit. Abstract, THE THIRTEENTH INTERNATIONAL CONFERENCE ON CONTINUOUS RENAL REPLACEMENT THERAPIES February 27- March 1, 2008 Hotel Del Coronado, San Diego CA
Arthur C. W. LAU,1 Mary S. M. Ip,2 Christopher K. W. LAI,3 K. L. CHOO,4 K. S. TANG,5 Loretta Y. C. YAM,1 Moira CHAN-YEUNG2VARIABILITY OF THE PREVALENCE OF UNDIAGNOSED AIRFLOW OBSTRUCTION IN SMOKERS USING DIFFERENT DIAGNOSTIC CRITERIA. (APSR 2007)
Ming-Lung Chuang, Hua Ting, Xing-Guo Sun, Arthur C.W. Lau, and Karlman Wasserman. Effect of Work Rate Increase and FIO2 on the Ventilation-CO2 Output Relationship. Abstract: International Union of Physiological Sciences Meeting in San Diego (Mar 31-Apr 5, 2005)
Lau ACW, So LKY, Liu HSY, Chim CS, Cheung NT, Chan H, Lam D, Cheung SL, Leung CSK, Yam LYC. Audit on a computerized nurse-operated triage system for the assignment of first appointments in the Medical Specialist Outpatient Department (SOPD) in Pamela Youde Nethersole Eastern Hospital. Abstract and oral presentation: HA Convention 2005
SO LKY, Lau ACW. Early and late outcomes of severe acute respiratory syndrome (SARS) treated with a standard protocol. Abstract: The 45th annual meeting of the Japanese Respiratory Society. The Journal of the Japananese Respiratory Society, v 43 supplement, Apr, 2005, p 111.
Johnny W Chan, Sai-On Ling, Agnes Lai, Fanny W Ko, Kam-Sing Tang, Arthur C Lau, Kahlin Choo, Wai-Cho Yu, Moira M Chan-Yeung, Mary S Ip. Determining the lower limits of normal of spirometric reference values for adult Chinese in Hong Kong. Abstract of CHEST 2005 at Montreal, Canada, Oct 29 – Nov 3, 2005.
Lau ACW. Ventilatory strategy in critical SARS. The 10th Congress of the Asian Pacific Society of Respirology and the 1st Joint Congress of the APSR/ACCP. Abstract of invited lecture. 13 Nov 2005.
Shum HP, Chan CK, Lo SH, Mo KL; Wong KS. Late Nephrologist referral of patients with Advanced renal failure was associated with poorer outcome and increased medical cost. Oral presentation in 2nd Asian Chapter Meeting of International Society for Peritoneal Dialysis (2005)
Lau ACW, So LKY, Miu FPL, Yung RWH, Poon E, Cheung TMT, Yam LYC. Analysis of the Long-term Treatment Outcomes of the Severe Acute Respiratory Syndrome in Pamela Youde Nethersole Eastern Hospital. Oral presentation and abstract, HK SARS Forum and HA Convention 8-11 May, 2004
Lau ACW. SARS: Respiratory Manifestation and Clinical Course. Abstract of invited lecture, HK SARS Forum and HA Convention 8-11 May, 2004
Poon E, Lau ACW, Yam LYC, Chan IYF, Chan MSM, Lau KY, So LKY, Cheung MT. Clinical and radiological predictors in patients with SARS. Abstract, HK SARS Forum and HA Convention 8-11 May, 2004
Mary S Ip1, Fanny W Ko2 , Arthur CW Lau3 , Wai Cho Yu4, Kam Shing Tang5 , Kahlin Choo6, Sai On Ling7, Johnny W Chan8, Moira Chan-Yeung1 on behalf of the Hong Kong Thoracic Society. Reference values of spirometry for adult Chinese in Hong Kong. Abstract to Asian Pacific Society of Respirology Symposium 2004
Arthur Chun-Wing Lau, Loretta Yin-Chun Yam, on behalf of the Hospital Authority SARS Collaborative Group (HASCOG. Prognostic Value of the PaO2/FiO2 (P/F) Ratio in Severe Acute Respiratory Syndrome. Abstract to Asian Pacific Society of Respirology Symposium 2004
Shum HP, Chan CK, Lo SH, Wong KS. Delayed initiation of dialysis in those referred early was associated with poorer short-term outcome and greater costs but no increased long-term morbidity. Poster presentation in 3rd World Congress of Nephrology (2004)
E Poon, CW Lau, LYC Yam, CW Lam, Messrs. M.M. Ho, K.M Leung, Grace Wong and C.S.K. Leung. Accessibility of Smoking Cessation Services: A Hospital Enquiry. Departments of Medicine, Pamela Youde Nethersole Eastern Hospital and Ruttonjee Hospital, HK, HK East Cluster Smoking Counseling and Cessation Centre. HA Convention 2003
FPL Miu, MT Cheung, KY Lau, KH Fung, LYC Yam, ACW Lau, LKY So, CK Ching, E Poon, YF Chan. Bronchial artery embolization in the treatment of massive haemoptysis. HKTS and ACCP, Annual Scientific Meeting 2003
L Yam, CW Lau, L So, H Liu, C Leung and Subspecialty Team Heads. Evaluation on implementation of SOP triage programme. Department of Medicine & SOPD, Pamela Youde Nethersole Eastern Hospital. HA Convention 2003
ACW Lau. Exercise physiology and respiratory medicine. Hong Kong College of Physicians and Hong Kong College of Paediatricians Joint Scientific Meeting, 11 – 12 October 2003. Abstract of invited lecture.
LYC Yam, ACW Lau, LKY So, HSY Liu, SL Cheung, CSK Leung. Towards sustainable medical specialist outpatient clinic management: A triage system for SOPD referrals. HA Convention, 2002
ACW Lau, Godwin Tat-Chi Leung, Pak-Tat Choi, Kwok-Wing Lo, and Loretta Yin-Chun Yam. Association between cardiopulmonary exercise testing (CPET) abnormalities and microalbuminuria in type 2 diabetic patients. Hong Kong Thoracic Society, Annual General Meeting, Mar 2002
ACW Lau, Kwok-Wing Lo, Godwin Tat-Chi Leung and Loretta Yin-Chun Yam. Cardiopulmonary exercise testing (CPET) in type 2 diabetic patients with normoalbuminuria and microalbuminuria. European Respiratory Society 22nd Annual Congress, Stockholm, 2002
E Poon, CW Lau, LYC Yam, CW Lam. An assessment of smoking in acute medical in-patients. British Thoracic Society Winter Meeting 2002
1999 and before
1. CW Lau, CH Lee, LYC Yam, CK Ching, MT Cheung. Oxygen Delivery in Hospital ‑ Quality and Cost. Hospital Authority Convention Abstract of Papers 1997: 76
2. CH Lee, CW Lau, LYC Yam, CK Ching, MT Cheung. Are pulse dose and continuous flow oxygen delivery systems equivalent in maintaining oxygen saturation?. HK Thoracic Society Abstract 1997
3. Cheung MT, Yam LYC, Lau CW, et al. Noninvasive positive pressure ventilation in acute respiratory failure: a Hong Kong experience. Proceedings of Chinese Society of Critical Care Medicine Inaugural Meeting 1997: 25 – 28
4. MT Cheung CW Lau, LYC Yam, et al. Non‑invasive positive pressure ventilation as primary ventilatory support for acute respiratory failure in Chinese Patients. European Society of Intensive Care Medicine, 11th Annual Congress Abstract. Intensive Care Med 1998; 24 (Suppl 1): S32
5. LYC Yam, MT Cheung, CW Lau, et al. Noninvasive positive pressure ventilation for acute respiratory failure, chronic obstructive pulmonary disease and other respiratory diseases. 5th Congress of the Asian Pacific Society of Respirology Abstract, Sydney, Australia. Respirology 1998; vol 3 (Suppl): A77
6. CW Lau, L Yam, et al. Predictive Factors for Frequent Hospital Readmission in COPD Patients. The XIX World Congress on Diseases of the Chest Abstract, Toronto. Chest 1998; 114(4): 320S
7. MT Cheung LYC Yam, CW Lau, et al. Noninvasive Positive Pressure Ventilation in Acute Respiratory Failure. Abstract, Hong Kong Thoracic Society Abstract 1998
8. MT Cheung, CW Lau, LYC Yam, et al. Noninvasive positive pressure ventilation as primary ventilatory support for acute respiratory failure in Chinese patients. Abstract, European Society of Intensive Care Medicine, 11th Annual Congress, Stockholm, Sweden, 1998
9. MT Cheung, LYC Yam, CW Lau, et al. A preliminary report on use of noninvasive positive pressure ventilation in acute respiratory failure management. (Abstract, The Hospital Authority Convention 1998)
10. Cheung MT, Lau CW, Yam LYC et al. ‘Noninvasive positive pressure ventilation as primary ventilatory support for acute respiratory failure in Chinese patients.’ Int Care Med 1998; 24: Suppl 1. S32
11. CW Lau, E Poon, LYC Yam, et al. Chronic obstructive pulmonary disease COPD and early unplanned readmissions to HA hospitals. Hospital Authority Convention Abstract of Papers 1999: P1 – 23: 48
12. CW Lau, LYC Yam, et al. Time to First Readmission after Hospital Discharge from Acute Exacerbation of Chronic Obstructive Pulmonary Disease COPD. Abstract, 20th Eastern Region Conference of the International Union Against Tuberculosis and Lung Diseases (IUATLD), Hong Kong, 1999
13. LKY So, CW Lau, CK Ching, LYC Yam, MT Cheung, E Poon. A 4.5‑year experience of managing patients with severe acute asthmatic attack. Abstract
14. MT Cheung LYC Yam, CW Lau, et al. Treatment of acute respiratory failure due to chronic obstructive pulmonary disease and other respiratory diseases. Hospital Authority Convention Abstract, 1999
15. MT Cheung, LYC Yam, CW Lau, et al. A 30‑month experience of noninvasive positive pressure ventilation for acute respiratory failure. Abstract, 20th Eastern Region Conference of the International Union Against Tuberculosis and Lung Disease (IUATLD), Hong Kong, 4 ‑ 7 June 1999
16. LKY So, CK Ching, CW Lau, et al. Comparison between mechanical ventilated and non‑ventilated patients with severe asthmatic attacks. Abstract, 20th Eastern Region Conference of the International Union Against Tuberculosis and Lung Disease (IUATLD), Hong Kong, 4 ‑ 7 June 1999
17. CK Ching, L Yam, L So, CW Lau, MT Cheung. Risk factors for mechanical ventilation in patients with severe asthma. Chest, Oct 1999 (Abstract).
ICU family satisfaction survey
Wu HL, Chan CS, Ho HC, Li C, Ma LH, So WY, Yan WW, Kwok N
Presented at the HA convention 2011
Official homepage (HA intranet): http://pynicu/main
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ICU Christmas Dinner 2008
By Dr LAU Chun Wing Arthur
Time for joy to celebrate the season! A moment of revelry as reward! The X’mas party of PYNEH ICU was held in 太古坊彩雲軒海鮮酒家 at Taikoo Place in the evening of 19 December 2008. There were more than 8 tables hosting 109 guests. Rounds of staff of different work shifts thronged to attend in turn.
Egyptian dance by Emily Chun
The event touched off by the Tahia's Dance, and continued with a round of Egyptian dance by our nurse dancer Ms Emily Chun, whose sexy body undulations to the loud Arabic and pop music rhythms accompanied by the electric guitar played by Billy, were cheered by deafening screaming and yelling of ICU staff and our lovely kids. Billy is a nurse in the F4 Oncology Ward, and he had rotated to work in our ICU a year ago.
Emily on stage
With continual choreographic and kinaesthetic tutorship under master dancers and open performance for years, Emily staged a repertoire of dancing skills, in one episode with several candlelights delicately balanced atop her head – the Candle Dance. The series of dance entertained us throughout the night, including the Suheir's Tabla accompanied by drum solo, followed by the music "I feel like dancing", and then the Cane Dance with the music Raksset El Assayia.
Two nurses and two doctors competed in squeezing oranges with bare hands to get out as much juice as possible in a minute. ICU Nurse Ben was able to fill up three quarters of a glass with juice and narrowly trumped his competitors. They celebrated by drinking all the juice up!
As juicy as possible - the orange-squeezing competition
There were almost prizes for all from the Lucky Draw, thanks to the sponsorship by both doctors and nurses. While Billy and Dr Joe Lee (our rotating MO from the Department of Medicine) played the guitar, Dr Arthur CW Lau sang along a funny version of 天各一方 (Zone 1 version), depicting a “love story” between a nurse and a doctor in the Zone 1 isolation room, who could not communicate with each other easily while wearing masks. Arthur’s drollery certainly brought up a lot of laughters, but believe it or not, the song left the audience wondering who the Romeo and Juliet were of this merely made-up story!
A group of nurses from the Guangdong Province joining the nursing training programme with our ICU danced and sang 天路 (Skyroad), a song commemorating the opening of the Qinghai–Tibet railway Railway (青藏鐵路). This railway was inaugurated on 1 July 2006. More than 960 km, or over 80% of the Golmud-Lhasa section, is at an altitude of more than 4,000 m, and thus it becomes the highest railroad in the world. There are 675 bridges, totalling 159.88 km, and about 550 km of the railway is laid on permafrost. Our Guangdong nurse 秋香 sang like a diva in the near-soprano range, while a young nurse enthralled us by backbending on the stage, followed by making a crisp sit-up with the dexterity like a professional dancer. Were they not nurses, they could have been real showbiz babies!
Lovely Guangdong nurses in "Skyroad"
ICU nurse Joan, quiet and serious we once thought, surprised us by singing a lip-synched version of Mama Mia, in which she gave a burlesque act of fumbling for some forgotten lyrics written on a piece of paper, but for a lip-synched song! After another round of lucky draw, she talked in Korean to introduce and then sang a Korean song Baby Baby. As the audience was cheering and waving in sync with rhythms, the whole place was flooded with flying balloons and confetti, inundated with joy and thundering applause.
Joe Lee, Billy, Ben and Arthur offered impromptu accompaniment by guitars and vocals, while 秋香 sang another song 黄土高坡 (Yellow Soil on Highlands). Our supporting staff Ailin soothed our ears with her sweet voice singing several melodious tunes, 月亮代表我的心 being one of them. A waiter asked, "Are you guys from the music industry?"
Arthur and Billy - Let's jam again next year!
When our mood escalated to climax and the music flowed, time was unwittingly half an hour to midnight. When we bid goodbye to friends and colleagues, wished each other a Merry Christmas and a Happy New Year, we are very certain that there is going to be a happier celebration for an even bigger harvest in the coming year of 2009.
10 December 2008
by Dr LAU Chun Wing Arthur
Our department had a wonderful dinner at the Amigo Restaurant celebrating the passing of the CCM Exit Examinations of our trainees. Our unit has produced a total of 6 new CCM fellows since November 2007. They are:
- Dr LAM Sin Man Grace
- Dr LEUNG Yuk Wah Natalie
- Dr LO Ho Yin Angus
- Dr SHUM Hoi Ping
- Dr WONG Ngai Pang
- Dr WU Hiu Lam Helen
Our seniors and trainers are Dr YAN Wing Wa, Dr LAU Chun Wing Arthur, Dr CHAN King Chung Kenny and Dr CHAN Kin Wai.
Really want the new fellows to know again that we all are so proud of them. Wish them every success in their coming career. We trainers will also continue to work hard; there are three more new CCM trainees coming in the year 2009!
26 January 2007
by Dr LAU Chun Wing Arthur
Dr Arthur Lau presenting the poem to Dr Alfred Chan
Dr CHAN Yan Fat Alfred was promoted Associate Consultant to the Intensive Care Unit of Caritas Medical Centre. Dr LAU Chun Wing Arthur wrote a Chinese poem to congratulate him on his promotion. The poem contains his name "CHAN", "YAN" and "FAT" in it. The poem reads, "A fierce tiger is setting out for a great journey, carrying three accreditations (AIM, Resp and CCM) and therefore making famous our name. He always exhibits an altruistic approach to his patients, so I must take out my good old wine to celebrate his promotion." "割股" means that in the old times in China, some very nice doctors would cut out a part of his own thigh flesh in order that their patients could be treated by eating the flesh as nutrients. Sounds incredible today, it is an ultimate exhibition of altruism and self-sacrifice in this profession.
The whole unit also had a farewell dinner with Dr Chan. A Chinese sword was presented to him as a souvenir, implying that he would use it to fight his way forward, and win!
11 December 2006
Our Department of Intensive Care was established in February 2006. A newly renovated ICU in the D10 ward was opened and we had a group photo to commemorate this major event.
Farewell Party with Dr Anne Leung
18 January 2008
by Dr LAU Chun Wing Arthur
Dr Anne Leung left our department for promotion to Queen Elizabeth Hospital as Consultant. We held a farewell part in a private kitchen restarant at South China Building in Central.
Benchtop study of leakages across the Portex, TaperGuard and Microcuff Endotracheal tubes under simulated clinical conditions
Lau AC, Lam SM, Yan WW. Hong Kong Med J. 2013 Jul 22.
OBJECTIVES. To compare three endotracheal tubes for leakage across the cuff (microaspiration) under a comprehensive set of simulated clinical situations. These were the Mallinckrodt TaperGuard (Covidien, US) with a tapered polyvinyl chloride cuff; the KimVent Microcuff (Kimberly-Clark Health Care, US) with a cylindrical polyurethane cuff, and a conventional Portex (Smiths Medical International Ltd, UK) with a globular polyvinyl chloride cuff.
DESIGN. A benchtop experimental study.
SETTING AND MATERIALS. A silicone cylinder serving as the model trachea was intubated with each of the three endotracheal tubes, one at a time. A total of 20 mL of water were added above the cuff and leakage measured every minute for 20 minutes under five simulated mechanical ventilation scenarios, including different positive end-expiratory pressure levels, and disconnection with and without spontaneous breathing efforts. Each scenario was studied under three cuff pressures of 10, 20 and 30 cm H2O, and then repeated with the application of a continuous suction force of 200 cm H2O, and leakage measured every minute for 3 minutes.
RESULTS. The outcome of interest was the cumulative amount of leakage. The Microcuff endotracheal tubes with an ultrathin polyurethane cuff consistently provided the best protection against microaspiration under all simulated clinical situations, followed by TaperGuard with a tapered cuff, and lastly Portex with a globular polyvinyl chloride cuff. Clinical scenarios associated with the greatest leakage were mechanical ventilation with zero positive end-expiratory pressure, circuit disconnection with spontaneous breathing efforts, application of suction, and a low cuff pressure.
CONCLUSIONS. Microcuff endotracheal tubes outperformed TaperGuard and Portex endotracheal tubes in preventing microaspiration, which is one of the major mechanisms for ventilator-associated pneumonia.
Timing for initiation of continuous renal replacement therapy in patients with septic shock and acute kidney injury
Shum HP, Chan KC, Kwan MC, Yeung AW, Cheung EW, Yan WW.; Ther Apher Dial. 2013 Jun;17(3):305-10.
The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into "early" (simplified RIFLE Risk) or "late" (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long-term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty-one (26%) underwent "early" while 89 (74%) had "late" CRRT. No significant difference was noted between groups on improvement of total SOFA/non-renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non-renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non-renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.
Application of endotoxin and cytokine adsorption haemofilter in septic acute kidney injury due to Gram-negative bacterial infection
Shum HP, Chan KC, Kwan MC, Yan WW.; Hong Kong Med J. 2013 May 6.
OBJECTIVE. Endotoxins and cytokines play an important role in the pathogenesis of multi-organ failure and mortality in patients suffering from severe Gram-negative bacterial infection. The aim of this study was to determine whether in patients with such infections, use of a haemofilter with enhanced endotoxin haemoadsorption and cytokine removal properties helps to overcome organ dysfunction.
DESIGN. Prospective case series study with historical controls.
SETTING. A regional hospital in Hong Kong.
PATIENTS. From October 2011 to June 2012, patients with sepsis-induced acute kidney injury due to Gram-negative bacteria were recruited. Continuous venovenous haemofiltration using oXiris haemofilter was performed. The patients' APACHE (Acute Physiology And Chronic Health Evaluation) II and inclusion criteria matched those of a series of selected historical controls who had been treated with continuous venovenous haemofiltration using polysulfone-based haemofilter from 2009 to 2011. The percentage reduction in the Sequential Organ Failure Assessment score by 24 and 48 hours, the percentage reduction of noradrenaline equivalent usage by 48 hours, as well as intensive care unit and hospital mortality in the two groups were compared.
RESULTS. Pre-treatment biochemical parameters and vasopressor use in the six patients undergoing the intervention and the 24 historical controls were similar. The mean circuit life of oXiris was about 61 hours. The Sequential Organ Failure Assessment score was significantly reduced by 37% at 48 hours post-initiation of oXiris-continuous venovenous haemofiltration versus an increment of 3% in the historical controls. No significant side-effect was detected. Mortality was similar in the two groups.
CONCLUSION. The haemofilter membrane with enhanced endotoxin adsorption and cytokine removal capacity was a safe alternative to traditional polysulfone-based continuous venovenous haemofiltration and expedited improvement in organ dysfunction.
Hyperimmune Intravenous Immunoglobulin Treatment: A Multicentre Double-Blind Randomized Controlled Trial for Patients with Severe A(H1N1)pdm09 Infection
Hung IF, To KK, Lee CK, Lee KL, Yan WW, Chan K, Chan WM, Ngai CW, Law KI, Chow FL, Liu R, Lai KY, Lau CC, Liu SH, Chan KH, Lin CK, Yuen KY.; Chest. 2013 Feb 28.
BACKGROUND Experience from influenza pandemics suggested that convalescent plasma treatment given within 4 to 5 days of symptom onset might be beneficial. However, robust treatment data is lacking.
METHODS This is a multicentre prospective double-blind randomized controlled trial. Convalescent plasma from patients who recovered from the 2009 pandemic influenza [A(H1N1)pdm09] infection was fractionated to hyperimmune intravenous immunoglobulin (H-IVIG) by CSL Biotherapies, Australia. Patients with severe A(H1N1)pdm09 infection on standard antiviral treatment requiring intensive care and ventilatory support were randomized to receive H-IVIG or normal IVIG manufactured before 2009 as control. Clinical outcome and adverse effects were compared.
RESULTS Between 2010 and 2011, thirty-five patients were randomized to receive H-IVIG (17 patients) or IVIG (18 patients). One defaulted patient was excluded from analysis. No adverse event related to treatment was reported. Baseline demographics and viral load before treatment were similar between the two groups. Serial respiratory viral load demonstrated that H-IVIG treatment was associated with significantly lower day 5 and 7 post-treatment viral load when compared to the control (p=0.04 and p=0.02 respectively). The initial serum cytokine level was significantly higher in the H-IVIG group but fell to similar level 3 days after treatment. Subgroup multivariate analysis of the 22 patients who received treatment within 5 days of symptom onset demonstrated that H-IVIG treatment was the only factor which independently reduced mortality [OR:0.14, 95% CI, 0.02-0.92; p=0.04].
CONCLUSIONS Treatment of severe A(H1N1)pdm09 infection with H-IVIG within 5 days of symptom onset was associated with a lower viral load and reduced mortality.ClinialTrials.gov (NCT01617317).
A retrospective review of the use of regional citrate anticoagulation in continuous venovenous hemofiltration for critically ill patients
Leung AK, Shum HP, Chan KC, Chan SC, Lai KY, Yan WW.; Crit Care Res Pract. 2013;2013:349512.
Background. The emergence of a commercially prepared citrate solution has revolutionized the use of RCA in the intensive care unit (ICU). The aim of this study was to evaluate the safety profile of a commercially prepared citrate solution.
Method. Predilution continuous venovenous hemofiltration (CVVH) was performed using Prismocitrate 10/2 at 2500 mL/h and a blood flow rate of 150 mL/min. Calcium chloride solution was infused to maintain ionized calcium within 1.0-1.2 mmol/L. An 8.4% sodium bicarbonate solution was infused separately. Treatment was stopped when the predefined clinical target was reached or the filter clotted.
Result. 58 sessions of citrate RCA were analyzed. The median circuit lifetime was 26.0 h (interquartile range IQR 21.2-44.3). The percentage of circuits lasting more than 12 h, 24 h, and 48 h was 94.6%, 58.9%, and 16.1%, respectively. There was no incidence of hypernatremia and median pH was <7.5. Hypomagnesemia and hypophosphatemia were detected in 41.6% and 17.6% of blood samples taken, respectively. Although 16 episodes had a total calcium/ionized calcium (total Ca/iCa) >2.5, only four patients had evidence of citrate accumulation.
Conclusion. The commercially prepared citrate solution could be used safely in critically ill patients who required CVVH with no major adverse events.
Ventilator Associated Pneumonia in Intensive Care Unit: Incidence, patient characteristics, outcome and validation of VAP-PIRO score in a local Chinese chort
Arthur Ming-Chit Kwan, King-Chung Chan, Arthur Chun-Wing Lau, Wing-Wa Yan; Crit Care & Shock 2012;15:111-9
Objective: Despite a systematic scoring system has been developed to assess the severity and to stratify the mortality risk of Ventilator-Associated Pneumonia (VAP), few clinical studies had published in validating this scoring system. We intend to study the incidence of VAP in a local Chinese cohort and to validate the VAP-PIRO (Predisposition, Insult, Response, Organ Dysfunction) score.
Design: A prospective, observational cohort study.
Setting: A 20-bed mixed medical-surgical adult Intensive Care Unit (ICU) of a regional referral centre serving 650,000 populations.
Patients and participants: 269 consecutive patients who had been intubated and mechanically ventilated for more than 24 hours during an 8-month study period.
Measurements and results: VAP was diagnosed by National Healthcare Safety Network (NHSN) PNU1 criteria. Clinical characteristics, medical resource use and outcome of the cohort were studied. The VAPPIRO score of each VAP case was calculated. The medical resource use and mortality in each PIRO risk group were compared. Of 269 patients admitted to ICU during the study period there were 59 VAP cases. The VAP incidence was 47.81 per 1,000 ventilator days. VAPPIRO score was unable to stratify medical resource use and mortality in our cohort.
Conclusion: VAP-PIRO score cannot significantly differentiate mortality and usage of medical resources in our cohort. This is likely due to the severity of VAP in our cohort is modest when compared to the original cohort.
Key words: Ventilator-Associated Pneumonia, Pneumonia, PIRO.
Regional citrate anticoagulation in predilution continuous venovenous hemofiltration using prismocitrate 10/2 solution
Ther Apher Dial. 2012 Feb;16(1):81-6.; Shum HP, Chan KC, Yan WW.
Regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) is associated with a longer filter life and fewer bleeding events. Complexity of the regimen is the major hurdle preventing widespread application. This study describes a simple predilution continuous venovenous hemofiltration (CVVH) protocol utilizing a commercially prepared replacement solution containing citrate (Prismocitrate 10/2). Ten patients with acute renal failure were evaluated. The Prismaflex system was used for predilution CVVH, with Prismocitrate 10/2 running at 2500 mL/h as the main predilution replacement. An 8.4% sodium bicarbonate solution was infused at 50 mL/h in the first 2 h followed by 30 mL/h; 10% calcium gluconate was given to achieve an ionized calcium (iCa) level of 1-1.2 mmol/L. The circuit was run for 72 h unless there was filter clotting, transportation was required, or the patient did not require further CRRT. Total treatment duration was 504.5 h. The post-dilution equivalent ultrafiltration rate was 32.9 mL/kg/h (interquartile range [IQR] 31.6-38.2) and the median circuit life was 50.3 h (IQR 25.5-72.0). None of the circuit was changed due to circuit clotting. The median systemic iCa was 0.98 mmol/L (IQR 0.91-1.08). The total calcium-to-iCa ratio was 2.33 (IQR 2.21-2.45). None of the patients developed hypernatremia (Na ≥ 150 mmol/L) or citrate toxicity (total Ca-to-iCa ratio > 2.5 plus increasing metabolic acidosis), and metabolic alkalosis (pH ≥ 7.5) occurred in one patient. This simple RCA CVVH protocol using commercially-prepared solution could be a feasible, relatively safe, and effective alternative to the conventional regimen for patients with a body weight up to 80 kg.
Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study
BMJ. 2011 Jun 13;342:d3245.MOSAICS Study Group
OBJECTIVES: To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance.
DESIGN:Prospective cohort study.
SETTING: 150 intensive care units in 16 Asian countries.
PARTICIPANTS: 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded.
MAIN OUTCOME MEASURE: Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles.
RESULTS: Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle.
CONCLUSIONS: While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.
Interaction between fluid balance and disease severity on patient outcome in the critically ill
Shum HP, Lee FM, Chan KC, Yan WW. J Crit Care. 2011 Apr 20. [Epub ahead of print]
PURPOSE: There is evidence in literature regarding the benefits of immediate aggressive fluid resuscitation together with conservative fluid management approach after initial stabilization. This retrospective study assesses the relationship between fluid balance during intensive care unit (ICU) stay and outcomes among general critically ill patients. In addition, we also aim to see the effect of fluid gain among patients with different disease severity.
METHODS:A total of 639 patients admitted into ICU who stayed for 3 days or more were evaluated. Fluid balances during ICU stay were recorded. A logistic regression analysis was performed to identify significant factors associated with hospital mortality.
RESULTS: Acute Physiology and Chronic Health Evaluation IV predicted risk of death, fluid balance on the second plus third ICU days, and total fluid balance during ICU stay were positively associated with hospital death. Significant positive fluid balance on first ICU day, in contrast, was negatively associated with hospital mortality. The positive correlation between standardized mortality ratio (Acute Physiology and Chronic Health Evaluation IV) and fluid gain on the second plus third ICU days increases with disease severity.
CONCLUSION:Early adequate fluid resuscitation together with conservative late fluid management may provide better patient outcomes. The effect of fluid management strategy on patient outcome may depend on the underlying disease severity.
Convalescent plasma treatment reduced mortality in patients with severe pandemic influenza A (H1N1) 2009 virus infection
Hung IF, To KK, Lee CK, Lee KL, Chan K, Yan WW, Liu R, Watt CL, Chan WM, Lai KY, Koo CK, Buckley T, Chow FL, Wong KK, Chan HS, Ching CK, Tang BS, Lau CC, Li IW, Liu SH, Chan KH, Lin CK, Yuen KY.; Clin Infect Dis. 2011 Feb 15;52(4):447-56. Epub 2011 Jan 19.
BACKGROUND:Experience from treating patients with Spanish influenza and influenza A(H5N1) suggested that convalescent plasma therapy might be beneficial. However, its efficacy in patients with severe pandemic influenza A(H1N1) 2009 virus (H1N1 2009) infection remained unknown.
METHODS:During the period from 1 September 2009 through 30 June 2010, we conducted a prospective cohort study by recruiting patients aged ≥ 18 years with severe H1N1 2009 infection requiring intensive care. Patients were offered treatment with convalescent plasma with a neutralizing antibody titer of ≥ 1:160, harvested by apheresis from patients recovering from H1N1 2009 infection. Clinical outcome was compared with that of patients who declined plasma treatment as the untreated controls.
RESULTS:Ninety-three patients with severe H1N1 2009 infection requiring intensive care were recruited. Twenty patients (21.5%) received plasma treatment. The treatment and control groups were matched by age, sex, and disease severity scores. Mortality in the treatment group was significantly lower than in the nontreatment group (20.0% vs 54.8%; P = .01). Multivariate analysis showed that plasma treatment reduced mortality (odds ratio [OR], .20; 95% confidence interval [CI], .06-.69; P = .011), whereas complication of acute renal failure was independently associated with death (OR, 3.79; 95% CI, 1.15-12.4; P = .028). Subgroup analysis of 44 patients with serial respiratory tract viral load and cytokine level demonstrated that plasma treatment was associated with significantly lower day 3, 5, and 7 viral load, compared with the control group (P < .05). The corresponding temporal levels of interleukin 6, interleukin 10, and tumor necrosis factor α (P < .05) were also lower in the treatment group.
CONCLUSIONS:Treatment of severe H1N1 2009 infection with convalescent plasma reduced respiratory tract viral load, serum cytokine response, and mortality.
Management and prevention of spontaneous pneumothorax using pleurodesis in Hong Kong
Chan JW, Ko FW, Ng CK, Yeung A, Yee WK, So LK, Lam B, Wong MM, Choo KL, Ho AS, Tse PY, Fung SL, Lo CK, Yu WC.; Int J Tuberc Lung Dis. 2011 Mar;15(3):385-90.
BACKGROUND: The practice of pleurodesis for the management and prevention of spontaneous pneumothorax (SP) is uncertain.
DESIGN: A retrospective multicentre analysis of patients admitted to 12 hospitals in Hong Kong with SP in 2004 and who subsequently underwent pleurodesis for the same episode.
RESULTS: Pleurodesis was performed in 394 episodes. Initial medical chemical pleurodesis was performed for 258 (65.5%) patients ('initial medical group'), while 136 (34.5%) underwent initial surgical pleurodesis ('initial surgical group'). Secondary spontaneous pneumothorax (SSP; 237 episodes, 60.2%) was the most common indication for pleurodesis; it was also performed after a first episode of primary spontaneous pneumothorax (PSP) in 22 episodes (5.6%). Tetracycline derivatives (172 episodes, 66.7%) were the most popular sclerosing agents in the initial medical group. Those in the initial medical group were older and were more likely to be males, have SSP, chronic obstructive pulmonary disease and a history of past pleurodesis (P < 0.05) compared to the initial surgical group. Compared to the tetracycline group, more patients who initially received talc slurry had the procedure performed by surgeons, had larger (≥2 cm) pneumothorax or required suction during initial drainage (P < 0.05).
CONCLUSIONS: Despite the availability of international guidelines, there is considerable variation in pleurodesis for SP.
Cast nephropathy with acute renal failure treated with high cut-off haemodialysis in a patient with multiple myeloma.
Shum HP, Chan KC, Chow CC, Kho BC, Yan WW. Hong Kong Med J. 2010 Dec;16(6):489-92.
We report a case of a Chinese woman who presented with multiple myeloma and acute renal failure due to cast nephropathy, with an extremely high serum lambda free light chain concentration. She was successfully treated with chemotherapy and high cut-off extended haemodialysis. High cut-off haemodialysis is a new treatment modality which can achieve rapid free light chain clearance. This may contribute to a better renal outcome and overall prognosis for patients with multiple myeloma.
Minocycline and talc slurry pleurodesis for patients with secondary spontaneous pneumothorax
Ng CK, Ko FW, Chan JW, Yeung A, Yee WK, So LK, Lam B, Wong MM, Choo KL, Ho AS, Tse PY, Fung SL, Lo CK, Yu WC.; Int J Tuberc Lung Dis. 2010 Oct;14(10):1342-6.
SETTING: Few studies have evaluated the sclerosing efficacy of minocycline, and none have specifically compared its sclerosing efficacy and safety profiles with talc slurry in secondary spontaneous pneumothorax (SSP).
DESIGN: A retrospective analysis was conducted in patients with SSP who underwent chemical pleurodesis from January to December 2004 with minocycline or talc slurry in 12 public hospitals of Hong Kong.
RESULT: There were 121 episodes of minocycline pleurodesis and 64 episodes of talc slurry pleurodesis. Immediate procedural failure were similar in the minocycline and talc slurry groups (21.5% vs. 28.1%, P = 0.31). Presence of interstitial lung disease, ≥ 2 previous episodes of pneumothorax, requiring mechanical ventilation during pleurodesis and persistent air leak before pleurodesis were independently associated with procedural failure. Pain was experienced in respectively 44.6% and 37.5% of the minocycline and the talc slurry groups. Pain was more common in patients receiving high doses of talc (≥ 5 g; P = 0.03). Respiratory distress was found in respectively 1.7% and 1.6% of the minocycline and talc slurry groups.
CONCLUSION: Minocycline and talc slurry had comparable sclerosing efficacy in SSP, with immediate success rates of >70%. Pain was the most common adverse effect and respiratory distress was uncommon. Both appeared to be effective and safe for chemical pleurodesis in SSP.
Helen Hiu-Lam Wu, Kenny King-Chun Chan, Arthur Chun-Wing Lau, Wing-Wa Yan. Crit Care & Shock (2010) 13:81-90 (Link)
Objective: The aim of the present study was to investigate both the outcomes and prognostic factors of ARF patients requiring RRT in our Intensive Care Unit.
Design: It was a retrospective observational study. Setting: Pamela Youde Nethersole Eastern Hospital, a 20-bed medico-surgical ICU.
Patients and participants: ARF patients who had received RRT from January 2005 to December 2006 were recruited.
Interventions: The primary outcome was hospital mortality. Secondary outcomes were: dialysis dependency at hospital discharge, ICU and hospital length of stay. Relationship between demographics, premorbidities and clinical parameters with primary outcome was studied.
Measurements and results: One hundred and thirty-five patients were included in the final analysis. Hospital
mortality rate was 63.7%. The median survival was 24 days (IQR 7 to 746 days). Mechanical ventilation (HR
2.96, 95% CI 2.04 to 3.89) and hepatorenal syndrome (HR 2.29, 95% CI 1.63 to 2.95) were independently
associated with hospital mortality. Dialysis dependency rate after hospital discharge as on day 60 was 4.1%.
Conclusion: ARF in ICU was associated with a high mortality rate which was correlated with hepatorenal
syndrome and mechanical ventilation. Most of the hospital survivors were free from dialysis.
Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of influenza A (H1N1)
Chan KK, Lee KL, Lam PK, Law KI, Joynt GM, Yan WW.; Hong Kong Med J. 2010 Dec;16(6):447-54.
OBJECTIVE. To report Hong Kong's experience with the use of extracorporeal membrane oxygenation for the treatment of acute respiratory distress syndrome caused by influenza A (H1N1).
DESIGN. Multi-centred, retrospective observational study.
SETTING. Intensive care units in Hong Kong.
PATIENTS. Recipients of extracorporeal membrane oxygenation for confirmed influenza A (H1N1) infection from 1 May 2009 to 28 February 2010.
MAIN OUTCOME MEASURE. Hospital mortality.
RESULTS. During the study period, 120 patients were mechanically ventilated in intensive care units, among whom seven received veno-venous extracorporeal membrane oxygenation. The median (interquartile range) age of the latter patients was 42 (39-50) years, four had various chronic illnesses and one had a body mass index of greater than 30 kg/m2. The median (interquartile range) time from symptom onset to hospital admission was 5 (4-7) days. Corresponding values for the duration of extracorporeal membrane oxygenation, mechanical ventilation, intensive care unit stay, and hospital stay were 6 (6-10), 19 (11-25), 19 (18-30), and 31 (25-55) days, respectively. One patient died (hospital mortality, 14%) and six made full recoveries. All seven patients received oseltamivir; in addition three received intravenous zanamivir, four received convalescent plasma, and one received hyperimmune immunoglobulin. Nosocomial infection was the commonest complication. There was no life- or limb-threatening complication directly attributable to extracorporeal membrane oxygenation.
CONCLUSION. In response to the pandemic of influenza A (H1N1), some intensive care units in Hong Kong were able to offer extracorporeal membrane oxygenation to selected cases. In this small series, patient outcomes were similar to those reported in other observational studies, indicating that intensive care units in Hong Kong are capable of successfully introducing this technology. However, the cost-effectiveness and optimal delivery of this strategy remain uncertain.
Clostridium perfringens liver abscess with massive haemolysis.
Ng H, Lam SM, Shum HP, Yan WW. Hong Kong Med J. 2010 Aug;16(4):310-2.
Liver abscesses are commonly caused by Enterobacteriaceae and anaerobes. This report is of a patient with liver abscess with massive haemolysis and multiorgan failure caused by Clostridium perfringens. Despite the reportedly high mortality rate and poor prognostic factors, the patient eventually recovered with prompt treatment.
Triage decisions and outcomes for patients with Triage Priority 3 on the Society of Critical Care Medicine scale
Hoi-Ping Shum, King-Chung Chan, Chun-Wing Lau, Anne Kit-Hung Leung, Kin-Wai Chan and Wing-Wa Yan. Crit Care Resusc 2010; 12: 42–49.
Objective: To identify factors associated with the triage decision for patients classified as Society of Critical Care Medicine (SCCM) Triage Priority 3, and their outcomes.
Design: Single-centre, prospective, observational cohort study.
Setting: General intensive care unit in a tertiary regional hospital, over the 9 months January to September 2007.
Patients: SCCM Triage Priority 3 patients.
Results: All patients were followed up for at least 6 months. Among the 1346 triaged patients, 250 were classified as SCCM Triage Priority 3. Fewer than a third of these (76, 30.4%) were admitted to the ICU. Medical patients were more likely to be rejected than surgical or neurosurgical patients. Those with a poorer physicianpredicted chance of long-term survival were more likely to be rejected than those with a better predicted prognosis. The MPMII0-predicted mortality was higher for those denied ICU admission. Non-postoperative status (odds ratio [OR], 26.3) and physician-predicted risk > 50% of death within 1 month (OR, 11.8) were independently correlated with denial of ICU admission in a multiple logistic regression analysis. Cox regression analysis showed that independent risk factors for mortality were denial of ICU admission (hazard ratio [HR], 2.80), higher MPMII0-predicted mortality (HR, 1.12 for every 10% increment) and the presence of renal disease as an admission diagnosis (HR, 2.28).
Conclusions: For SCCM Triage Priority 3 patients, postoperative status and better physician-predicted prognosis correlated with ICU admission. Patients had lower medium-term survival if they were denied ICU admission, or had higher MPMII0-predicted mortality, or renal disease as the admission diagnosis.
Over 8 years experience on severe acute poisoning requiring intensive care in Hong Kong, China.
Lam SM, Lau AC, Yan WW.Hum Exp Toxicol. 2010 Feb 9. [Epub ahead of print]
In order to obtain up-to-date information on the pattern of severe acute poisoning and the characteristics and outcomes of these patients, 265 consecutive patients admitted to an intensive care unit in Hong Kong for acute poisoning from January 2000 to May 2008 were studied retrospectively. Benzodiazepine (25.3%), alcohol (23%), tricyclic antidepressant (17.4%), and carbon monoxide (15.1%) were the four commonest poisons encountered. Impaired consciousness was common and intubation was required in 67.9% of admissions, with a median duration of mechanical ventilation of less than 1 day. The overall mortality was 3.0%. Among the 257 survivors, the median lengths of stay in the intensive care unit and acute hospital (excluding days spent in psychiatric ward and convalescent hospital) were less than 1 day and 3 days, respectively. Factors associated with a longer length of stay included age of 65 or older, presence of comorbidity, Acute Physiology and Chronic Health Evaluation II score of 25 or greater, and development of shock, rhabdomyolysis, and aspiration pneumonia, while alcohol intoxication was associated with a shorter stay. This is the largest study of its kind in the Chinese population and provided information on the pattern of severe acute poisoning requiring intensive care admission and the outcomes of the patients concerned.
Management of patients admitted with pneumothorax: a multi-centre study of the practice and outcomes in Hong Kong
Chan JW, Ko FW, Ng CK, Yeung AW, Yee WK, So LK, Lam B, Wong MM, Choo KL, Ho AS, Tse PY, Fung SL, Lo CK, Yu WC.
OBJECTIVE: To examine the management practice of pneumothorax in hospitalised patients in Hong Kong, especially the choice of drainage options and their success rates, as well as the factors associated with procedural failures.
DESIGN: Retrospective study.
SETTING: Multi-centre study involving 12 public hospitals in Hong Kong.
PATIENTS: All adult patients admitted as an emergency in the year 2004 with a discharge diagnosis of 'pneumothorax' were included. Data on the management and outcomes of the various types of pneumothoraces were collected from their case records.
RESULTS: Altogether these patients had 1091 episodes (476 primary spontaneous pneumothoraces, 483 secondary spontaneous pneumothoraces, 87 iatrogenic pneumothoraces, and 45 traumatic pneumothoraces). Conservative treatment was offered in 182 (17%) episodes, which were more common among patients with small primary spontaneous pneumothoraces (71%). Simple aspiration was performed to treat 122 (11%) of such episodes, and had a success rate of 15%. Aspiration failure was associated with having a pneumothorax of size 2 cm or larger (odds ratio=3.7; 95% confidence interval, 1.2-11.5; P=0.03) and a smoking history (4.1; 1.2-14.3; P=0.03). Intercostal tube drainage was employed in 890 (82%) episodes, with a success rate of 77%. Failure of intercostal tube drainage was associated with application of suction (odds ratio=4.1; 95% confidence interval, 2.8-5.9; P<0.001) and presence of any tube complications (1.55; 1.0-2.3; P=0.03). Small-bore catheters (<14 French) were used in 12 (1%) of the episodes only. Tube complications were encountered in 214 (24%) episodes.
CONCLUSION: Notwithstanding recommendations from international guidelines, simple aspiration and intercostal tube drainage with small-bore catheters were not commonly employed in the management of hospitalised patients with the various types of pneumothoraces in Hong Kong.
Delayed Clearance of Viral Load and Marked Cytokine Activation in Severe Cases of Pandemic H1N1 2009 Influenza Virus Infection.
To KK, Hung IF, Li IW, Lee KL, Koo CK, Yan WW, Liu R, Ho KY, Chu KH, Watt CL, Luk WK, Lai KY, Chow FL, Mok T, Buckley T, Chan JF, Wong SS, Zheng B, Chen H, Lau CC, Tse H, Cheng VC, Chan KH, Yuen KY. Clin Infect Dis. 2010 Feb 5. [Epub ahead of print]
Background. Infections caused by the pandemic H1N1 2009 influenza virus range from mild upper respiratory tract syndromes to fatal diseases. However, studies comparing virological and immunological profile of different clinical severity are lacking. Methods. We conducted a retrospective cohort study of 74 patients with pandemic H1N1 infection, including 23 patients who either developed acute respiratory distress syndrome (ARDS) or died (ARDS-death group), 14 patients with desaturation requiring oxygen supplementation and who survived without ARDS (survived-without-ARDS group), and 37 patients with mild disease without desaturation (mild-disease group). We compared their pattern of clinical disease, viral load, and immunological profile. Results. Patients with severe disease were older, more likely to be obese or having underlying diseases, and had lower respiratory tract symptoms, especially dyspnea at presentation. The ARDS-death group had a slower decline in nasopharyngeal viral loads, had higher plasma levels of proinflammatory cytokines and chemokines, and were more likely to have bacterial coinfections (30.4%), myocarditis (21.7%), or viremia (13.0%) than patients in the survived-without-ARDS or the mild-disease groups. Reactive hemophagocytosis, thrombotic phenomena, lymphoid atrophy, diffuse alveolar damage, and multiorgan dysfunction similar to fatal avian influenza A H5N1 infection were found at postmortem examinations. Conclusions. The slower control of viral load and immunodysregulation in severe cases mandate the search for more effective antiviral and immunomodulatory regimens to stop the excessive cytokine activation resulting in ARDS and death.
Natalie YW Leung, Arthur CW Lau, Kenny KC Chan, WW Yan. Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review. Hong Kong Med J 2009;15:Epub 2009 Dec 8
Objective To review the characteristics and health-related quality-of-life outcomes of obstetric patients admitted to the Intensive Care Unit.
Design Retrospective cohort study.
Setting A regional hospital in Hong Kong.
Patients Consecutive obstetric patients admitted to the Intensive Care Unit of Pamela Youde Nethersole Eastern Hospital from January 1998 to December 2007.
Results Fifty obstetric patients (mean [standard deviation] age, 31  years; mean gestational age, 34  weeks) were analysed. The most common obstetric cause of admission was postpartum haemorrhage (n=19, 38%), followed by pregnancy-associated hypertension (n=7, 14%). The commonest non-obstetric cause of admission was sepsis (n=7, 14%). The commonest intervention was arterial line insertion (n=33, 66%) and mechanical ventilation (n=29, 58%). Maternal mortality was 6% (n=3), while the perinatal mortality rate was 8% (n=4). The average Short Form–36 Health Survey scores of our patients were lower than the norm for the Hong Kong population of the same age and gender. Conclusion Postpartum haemorrhage and pregnancy-associated hypertension were the most common causes of admission to our Intensive Care Unit. Overall mortality was low. Long-term
health-related quality of life in discharged patients was lower than the norm of the Hong Kong population. Appropriate antenatal care is important in preventing obstetric complications. Continued psychosocial follow-up of discharged patients has to be implemented.
Dr. Wing-wa YAN. Update of Renal Replacement Therapy in the ICU. The Hong Kong Medical Diary, vol 14, no 9, 13-18
In 2004, the term Acute Kidney Injury (AKI) was proposed to represent the entire spectrum of acute renal failure (ARF) with clinical manifestations ranging from a minimal elevation in serum creatinine to anuric renal failure.1 The reported prevalence of AKI in critically ill patients could be as high as 25% in some developed countries, and only about 4% of this group received renal replacement therapy (RRT), with an ensuing hospital mortality up to 60%. Controversies exist in many aspects of RRT for AKI despite decades of development. However, definitive findings on the dose of RRT were available last year. It is hoped that, with the continued international collaboration, a clearer picture would emerge in other areas of RRT.
Complete article here.
Dr LAM Sin Man Grace and Dr LAU Chun Wing Arthur, April 20092009 Alveolopleural or Bronchopleural Fistula - From the Critical Care Physicians' Perspective. Newsletter of The Hong Kong Thoracic Society, The American College of Chest Physicians (Hong Kong and Macau Chapter) and The Hong Kong Lung Foundation, vol 19, no 1, Mar/Apr 2009.
Introduction: In the following article, we illustrate the differences between alveolopleural fistula (APF) and bronchopleural fistula (BPF) with a review on their management through the presentation of a case recently encountered in the intensive care unit (ICU).
Case presentation: A 70-year-old ex-smoker with chronic obstructive pulmonary disease who was capable of caring for himself was admitted in September 2008 for his first episode of left-sided spontaneous pneumothorax. A chest drain was inserted, but the leak still had not healed by three weeks. He therefore underwent a video-assisted thoracoscopy (VAT). Intraoperatively, in an attempt to free the left lung from adhesions, the lung surface was torn and talc poudrage was thus abandoned. VAT was repeated one week later, but had to be converted to an open thoracotomy to identify the site of air leak, which was found at the apex of his left upper lobe. It was repaired and two new chest drains were inserted. Despite surgical repair, air leak persisted postoperatively. Two months into this admission, the patient developed right-sided spontaneous pneumothorax in addition to the persistent air leak on the left. Multiple chest drains were inserted into the right pleural cavity through which suction was applied. He developed respiratory failure two weeks later and was admitted to the ICU. Chest X-ray showed air-space consolidation in both lower lobes. The lungs were fully expanded, but air leak persisted bilaterally.
Complete article here.
Anne KH Leung, WW Yan. Renal replacement therapy in critically ill patients. Hong Kong Med J 2009; 15:122- 9
OBJECTIVE. To provide updated information (including on treatment) in relation to renal replacement therapy in critically ill patients.
DATA SOURCES AND STUDY SELECTION. Literature search of Medline and PubMed till June 2008.
DATA EXTRACTION. Original studies, literature review, and book chapters.
DATA SYNTHESIS. The prevalence of acute renal failure in critically ill patients remains high and mortality is up to 60%. Both the practice of renal replacement therapy (continuous against intermittent, haemofiltration against haemodialysis) and patient outcomes vary widely between studies. To better understand this heterogeneous group of patients, a unified classification of acute renal failure proposed by the Acute Dialysis Quality Initiative allows better understanding of the epidemiology and outcome of this disease. Similar to patients with chronic renal failure, there exists a direct relationship between the dose of dialysis and survival; 35 mL/kg/h is the accepted norm. However, this traditional practice is being challenged by recent trials. Although the use of citrate as anticoagulant in renal replacement therapy can prolong circuit patency and decrease bleeding risk, its use is limited by the complex set up and metabolic problems.
CONCLUSIONS. The RIFLE classification allows an accurate description of the epidemiology and outcome of critically ill patients with acute renal failure. The well-accepted continuous renal replacement therapy dose of 35 mL/kg/h in critically ill patients needs further verification from ongoing clinical trials. The complex set-up and the use of citrate anticoagulant has limited the use of such dialysis, which can nevertheless be overcome with the support of pharmaceutical companies.
Hong Kong Med J 2009;15:122-9
Key words: Critical illness; Kidney failure, acute; Renal dialysis; Renal replacement therapy; Treatment outcome
Ching-Kit Chan, Richard Li, HP Shum, Stanley HK Lo, Kenny KC Chan, KS Wong, TH Tsoi, WW Yan. Star fruit intoxication successfully treated by charcoal haemoperfusion and intensive haemofiltration. Hong Kong Med J 2009;15:149-52
We report on a case of an elderly woman with chronic renal impairment, secondary to diabetic nephropathy, who developed a deep coma and seizure shortly after consumption of star fruit. She was managed in the intensive care unit, and her consciousness level improved dramatically after an 8-hour charcoal haemoperfusion and 30 hours of continuous haemofiltration. There were no long-term neurological or renal sequelae 9 months later. Early recognition of this condition, intensive dialytic therapy and supportive measures, as well as early initiation of charcoal haemoperfusion may improve the management of this potentially treatable condition.
Key words: Diabetic nephropathies; Food poisoning; Fruit/poisoning; Kidney
Arthur Chun-Wing Lau, Wing-Wa Yan. Non-invasive Ventilation for Acute Respiratory Failure: Evidence and Experience. Medical Progress Nov, 2008, p 525 to 530
Introduction: Non-invasive positive-pressure ventilation (NIV) is the delivery of mechanically assisted breaths by non-invasive means (ie, without the
need for endotracheal intubation). Possible benefits of NIV include the avoidance of the complications of mechanical ventilation; enhancement of patient comfort; reductions in morbidity, mortality, intensive care unit (ICU) and hospital lengths of stay (LOS); and lower cost. In Hong Kong, NIV has been in common use for more than 15 years. Overseas, NIV was employed in 20% of ventilator starts, but utilization rates varied from 0% to 50% among different hospitals. The main reason for the low utilization rate was 'physicians' lack of knowledge'.1 This article reviews the evidence and summarizes the authors' experience of NIV use for acute respiratory failure.
BACKGROUND: In unconscious ventilated patients, various eye protective measures have been used to prevent corneal abrasions. Two randomized controlled studies in Australia had compared the effectiveness of polyethylene films and eye instillations to prevent corneal abrasions but results were inconsistent. The local acceptance of polyethylene films as a standard eye protective measure is still limited. OBJECTIVES: Our study aims to compare the effectiveness of polyethylene covers (Gladwrap) with lanolin (Duratears) eye ointment in the prevention of corneal abrasions in critically ill patients. DESIGN: A prospective randomized controlled study was conducted between April 2004 and December 2005. SETTING AND PARTICIPANTS: One hundred and twenty ventilated patients admitted to the intensive care unit (ICU) were randomly assigned to receive either polyethylene covers or lanolin eye ointment to prevent corneal abrasions. METHODS: All participants received a standard eye care regime together with the eye protective interventions. A fluorescein stain test was performed by the eye care team daily and then weekly to detect any corneal abrasions. RESULTS: Four participants were not included in the data analysis as they died soon after commencement of the study. A total of 116 patients were included in the final analysis. Of the seven patients (6.0%) that had a positive fluorescein test, four (6.8%) were in the polyethylene covers group (n=59) and three (5.3%) were in the lanolin eye ointment group (n=57). This was not statistically significant (p=0.519). One patient in the lanolin eye ointment group had an eye infection. Upon follow-up of those patients with positive fluorescein test results, two patients spontaneously converted to stain negative within 24h and two patients died before the ophthalmologist's assessment. The remaining three patients were diagnosed to have epithelial cell loss without corneal abrasions. CONCLUSIONS: With the implementation of a standardized eye care protocol, polyethylene cover is found to be equally effective in preventing corneal abrasions when compared with lanolin eye ointment. The additional benefit of polyethylene cover as a physical barrier to protect patients' eyes needed further evaluation.
A 53-year-old lady with blood-stained sputum and pleuritic pain had a lingular opacity on CXR which failed to resolve. A bronchial aspirate and transbronchial biopsy revealed features of bronchocentric granulomatosis with dichotomous branching hyphae suggestive of Aspergillus infection. However, subsequent fungal culture grew Pseudallescheria boydii. This case demonstrates the similarity of clinical and histological features caused by these two fungi. This appears to be the first reported case of pulmonary pseudallescheria with a bronchocentric granulomatous response.
Ching CK, Lai CK, Poon WT, Wong EN, Yan WW, Chan AY, Mak TW. Hazards posed by a banned drug--phenformin is still hanging around.Hong Kong Med J. 2008 Feb;14(1):50-4. Hospital Authority Toxicology Reference Laboratory, Princess Margaret Hospital, Laichikok, Hong Kong.
The Hospital Authority Toxicology Reference Laboratory confirmed six cases of phenformin use, with or without complications, from July 2005 to November 2006. Two of the patients presented with potentially fatal phenformin-induced lactic acidosis. Phenformin was found (or suspected to be) adulterating Chinese proprietary medicine in five of the six cases. We report these six cases to highlight the underrecognised hazards posed by phenformin, a banned drug in Hong Kong.
Lau AC, Ip MS, Lai CK, Choo KL, Tang KS, Yam LY, Chan-Yeung M. Variability of the prevalence of undiagnosed airflow obstruction in smokers using different diagnostic criteria. Chest. 2008 Jan;133(1):42-8. Epub 2007 Nov 7. Department of Intensive Care, The University of Hong Kong, Queen Mary Hospital Pokfulam, Hong Kong SAR, China.
PURPOSES: To estimate the prevalence of undiagnosed airflow obstruction (AFO) in Hong Kong smokers with no previous diagnosis of respiratory disease, and to assess its variability when applying different prediction equations and diagnostic criteria. METHODS: A multicenter, population-based, cross-sectional prevalence study was performed in smokers aged 20 to 80 years. Three different criteria (fixed 70% [Global Initiative for Chronic Obstructive Lung Disease and British Thoracic Society], fixed 75%, and European Respiratory Society [ERS]) were applied to define a lower limit of normal (LLN) of the FEV(1)/FVC ratio to compare with the Hong Kong Chinese reference equation (criterion 1), which had used a distribution-free method to obtain the lower fifth percentile of FEV(1)/FVC ratio as the LLN. RESULTS: In 525 male patients, using criterion 1 (local internal prediction equation) and defining AFO as FEV(1)/FVC less than LLN, the overall prevalence of AFO was 13.7%: 8.3% in age > or = 20 to 40 years, 14.0% in age > or = 40 to 60 years, and 17.8% in age > or = 60 to 80 years. When the local internal prediction equation was used as the comparison reference, the fixed-ratio methods tended to miss AFO in younger age groups and overdiagnose AFO in old age, while the ERS criteria, which uses an almost lower fifth percentile-equivalent method, showed less of such a trend but still only showed moderate agreement with criterion 1. CONCLUSIONS: Undiagnosed AFO was prevalent in Hong Kong smokers. Estimated prevalence rates were highly affected by the criteria used to define AFO. The predicted lower fifth percentile values calculated from a local reference equation as the LLN of FEV(1)/FVC ratio should be used for the diagnosis of AFO.
Lithium overdose causing non-convulsive status epilepticus--the importance of lithium levels and the electroencephalography in diagnosis
Yip KK, Yeung WT. Hong Kong Med J. 2007 Dec;13(6):471-4.
We report a case of lithium overdose in a patient who presented in non-convulsive status epilepticus. The lithium toxicity was probably due to interaction with Moduretic. The diagnosis was not suspected until electroencephalography was performed. This case underscores the importance of therapeutic drug level monitoring of lithium, especially where toxicity is suspected, and the indispensable role electroencephalography plays by allowing a correct diagnosis to be made promptly.
BACKGROUND AND OBJECTIVE: This study was conducted to define normal reference values and lower limits of normal (LLN) for single-breath carbon monoxide diffusing capacity (DLco) and DLco per unit of alveolar volume (Kco) for Chinese adults in Hong Kong. METHODS: Healthy non-smoking men and women aged 18-80 years were recruited by random digit dialing. DLco and Kco were measured according to American Thoracic Society standards. Reference equations were obtained by multiple linear regression; LLN were derived by distribution-free method for estimation of age-related centiles. RESULTS: Tests from 568 subjects (259 men, 309 women) were analysed. DLco declined with age in both genders, and increased with height and the interaction term of height and age in men and women, respectively. Considering Hb values did not improve the reference equations. Kco declined with age and increased with weight in both genders, while height and its interaction term with age were additional determinants in women. The reference DLco was lower than some Caucasian values, and was only explained partially by a smaller body size and alveolar volume in Chinese. The distribution-free method yielded better overall approximation to the fifth percentile compared with the traditional method of determining LLN. CONCLUSIONS: The equations for reference values and LLN of diffusing capacity derived in this study are of clinical relevance to Chinese subjects.
Yam LY, Lau AC, Lai FY, Shung E, Chan J, Wong V; Hong Kong Hospital Authority SARS Collaborative Group (HASCOG). Corticosteroid treatment of severe acute respiratory syndrome in Hong Kong. J Infect. 2007 Jan;54(1):28-39. Epub 2006 Mar 15. Division of Respiratory and Critical Care Medicine, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Hong Kong SAR, China.
BACKGROUND: The patterns of corticosteroids usage in severe acute respiratory syndrome (SARS) and associated treatment outcomes in Hong Kong were studied. METHOD: Patients> or =18 years old who either had not received corticosteroid or had taken corticosteroids within 14 days from symptom onset were included. Patients receiving corticosteroids beyond 15 days or other investigational treatment within 21 days from symptom onset were excluded. Of 1313 eligible patients, 1287 with major corticosteroid dosage-type combinations were analysed. RESULTS: Crude death rate was lower among 1188 steroid-treated patients compared to 99 patients in Group No Steroid (17.0% vs. 28.3%). Among four corticosteroid groups studied, mortality was lowest in the low-dose oral prednisolone (Group P) and high-dose methylprednisolone (Group MP) groups. On multivariate analysis of the corticosteroid groups, independent factors related to death were: corticosteroid group, older age, co-morbidity, worse chest X-ray score, worse respiratory status at Days 8-10 and higher admission white cell count. Again Groups P and MP had significantly lower adjusted odds ratios for death and lower bacterial and fungal culture rates. Despite worse chest X-ray scores and higher cumulative corticosteroid dosages in Group MP compared to Group P, fewer patients required rescue pulsed corticosteroid. Patients on hydrocortisone (Group HC) had the highest positive culture rates. CONCLUSION: We speculate that corticosteroid with higher in-vitro inflammatory potency administered at timing and dosages commensurate with disease severity may be conducive to better outcome from SARS as a consequence of more effective control of immunopathological lung damage.
STUDY OBJECTIVES: The accuracy of reference values of lung function is important for assessment of severity and functional impairment of respiratory diseases. The aim of the study was to establish updated prediction formulae of spirometric parameters for Hong Kong Chinese and to compare the reference values with those derived from other studies in white and Chinese subjects. DESIGN: Cross-sectional multicenter study. SETTING: Lung function laboratories of eight regional hospitals in Hong Kong. PARTICIPANTS: Subjects were recruited by random-digit dialing. One thousand one hundred seventy-six subjects who fulfilled recruitment criteria underwent spirometry. MEASUREMENTS: Spirometry was performed according to American Thoracic Society recommendations, and the technique was standardized among the eight participating lung function laboratories. RESULTS: Evaluable data of 1,089 (494 men and 595 women) healthy nonsmokers aged 18 to 80 years were analyzed. Age and height were found to be the major determinants of FEV1 and FVC, with a linear decline of height-adjusted values with age in both sexes. Spirometric values of this population have increased compared to Chinese populations of similar sex, age, and height two decades ago. Reference values derived from white populations were higher than our values by 5 to 19%, and the degree of overestimation varied with age, sex, and lung function parameter. We also demonstrated that the blanket application of correction factors for Asian populations may not be appropriate. In this study cohort, the distribution-free estimation of age-related centiles was more appropriate for the determination of lower limits of normal. CONCLUSIONS: Our findings underscore the need to use reference values based on updated data derived from local populations or those matched for ethnicity and other sociodemographic characteristics.
Lau AC, Yam LY, So LK. Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS). Int J Med Sci. 2004;1(1):1-10. Epub 2004 Mar 10. Division of Respiratory and Critical Care Medicine, Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, PR China.
Severe acute respiratory syndrome (SARS) is frequently complicated with acute respiratory failure. In this article, we aim to focus on the management of the subgroup of SARS patients who are critically ill. Most SARS patients would require high flow oxygen supplementation, 20-30% required intensive care unit (ICU) or high dependency care, and 13-26% developed acute respiratory distress syndrome (ARDS). In some of these patients, the clinical course can progress relentlessly to septic shock and/or multiple organ dysfunction syndrome (MODS). The management of critically ill SARS patients requires timely institution of pharmacotherapy where applicable and supportive treatment (oxygen therapy, noninvasive and invasive ventilation). Superimposed bacterial and other opportunistic infections are common, especially in those treated with mechanical ventilation. Subcutaneous emphysema, pneumothoraces and pneumomediastinum may arise spontaneously or as a result of positive ventilatory assistance. Older age is a consistently a poor prognostic factor. Appropriate use of personal protection equipment and adherence to infection control measures is mandatory for effective infection control. Much of the knowledge about the clinical aspects of SARS is based on retrospective observational data and randomized-controlled trials are required for confirmation. Physicians and scientists all over the world should collaborate to study this condition which may potentially threaten human existence.
OBJECTIVES: To study the effectiveness of noninvasive positive pressure ventilation (NIPPV) in the treatment of acute respiratory failure (ARF) in severe acute respiratory syndrome (SARS), and the associated infection risk. METHODS: All patients with the diagnosis of probable SARS admitted to a regional hospital in Hong Kong from March 9 to April 28, 2003, and who had SARS-related respiratory distress complications were recruited for NIPPV usage. The health status of all health-care workers working in the NIPPV wards was closely monitored, and consent was obtained to check serum for coronavirus serology. Patient outcomes and the risk of SARS transmission to health-care workers were assessed. RESULTS: NIPPV was applied to 20 patients (11 male patients) with ARF secondary to SARS. Mean age was 51.4 years, and mean acute physiology and chronic health evaluation II score was 5.35. Coronavirus serology was positive in 95% (19 of 20 patients). NIPPV was started 9.6 days (mean) from symptom onset, and mean duration of NIPPV usage was 84.3 h. Endotracheal intubation was avoided in 14 patients (70%), in whom the length of ICU stay was shorter (3.1 days vs 21.3 days, p < 0.001) and the chest radiography score within 24 h of NIPPV was lower (15.1 vs 22.5, p = 0.005) compared to intubated patients. Intubation avoidance was predicted by a marked reduction in respiratory rate (9.2 breaths/min) and supplemental oxygen requirement (3.1 L/min) within 24 h of NIPPV. Complications were few and reversible. There were no infections among the 105 health-care workers caring for the patients receiving NIPPV. CONCLUSIONS: NIPPV was effective in the treatment of ARF in the patients with SARS studied, and its use was safe for health-care workers.
Tse TS, Tsui KL, Yam LY, So LK, Lau AC, Chan KK, Li SK. Occult pneumomediastinum in a SARS patient presenting as recurrent chest pain and acute ECG changes mimicking acute coronary syndrome. Respirology. 2004 Jun;9(2):271-3. Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China.
OBJECTIVE: Severe acute respiratory syndrome (SARS) is a newly emergent disease due to a novel coronavirus, which caused outbreaks worldwide. METHODOLOGY: We report a SARS patient who had developed recurrent chest pain and acute T-wave inversion over the precordial leads on electrocardiography (ECG). Results: She developed progressive subcutaneous emphysema a few days later. Her CXR showed features suggestive of pneumomediastinum, which was confirmed by high-resolution CT scan of the thorax. CONCLUSION: Pneumomediastinum should be considered in SARS patients as a possible cause of chest pain and ECG changes that mimic acute coronary syndrome.
OBJECTIVE: There is so far no consensus on the optimal treatment strategy for the coronavirus-associated severe acute respiratory syndrome (SARS). We aimed to analyse the outcomes of a standard treatment strategy comprising antibiotics, a combination of ribavirin, a 3-week step-down course of corticosteroids, and the possibility of pulsed methylprednisolone rescue in the event of deterioration. METHODOLOGY: This was a prospective cohort study performed at a major public-funded hospital in Hong Kong. Eighty-eight World Health Organisation/Centers for Disease Control and Prevention probable cases of SARS (97% laboratory-confirmed) were treated with a standard protocol previously reported. Seventy-one patients treated de novo were analysed in detail with regard to time to clinical stabilization after combination treatment, requirement of additional therapy (pulsed methylprednisolone; assisted ventilation); and final outcomes (recovery, mortality). RESULTS: The mean age was 42. Twenty-one patients (24%) had comorbidities. Three of 71 treated de novo recovered with antibiotics alone. The remaining 68 received combination treatment at a mean of 5.8 days after symptom onset, of whom 30 subsequently required pulsed methylprednisolone rescue (independent predictors: older age and higher LDH) and 18 required assisted ventilation (independent predictors: older age, higher oxygen requirement and creatinine level). Their median time to clinical stabilization was 8.0 days after combination treatment (independent predictor for longer time to stabilization: median age of 41 or above). Common complications were hyperglycaemia (58%), pneumo-mediastinum/thoraces (13%), psychiatric manifestations (7%) and ventilator-associated pneumonia (2%). One patient (1%) died of SARS-related respiratory failure. All-cause mortality was 3.4%, occurring in patients aged > 65 years only. None of the discharged survivors required continuation of oxygen therapy. CONCLUSIONS: This standard treatment protocol resulted in overall satisfactory outcomes. Randomized controlled trial is suggested to confirm its efficacy.
STUDY OBJECTIVE: Microalbuminuria in diabetes mellitus is a risk factor for cardiovascular disease. We hypothesized that microalbuminuria in type 2 diabetic patients is related to impaired cardiopulmonary function during exercise, and that the severity of impairment is correlated with the degree of microalbuminuria. DESIGN: Twenty of each of the following categories of subjects performed symptom-limited cardiopulmonary exercise testing on a cycle ergometer: (1) type 2 diabetic patients with normoalbuminuria (daily urinary albumin excretion [UAE] < 30 mg/d); (2) type 2 diabetic patients with microalbuminuria (daily UAE, 30 to 300 mg/d); and (3) normal control subjects. MEASUREMENTS AND RESULTS: Oxygen consumption (VO(2)) of patients with microalbuminuria was lower than that of control subjects at anaerobic threshold (AT) [p < 0.001], and was lower than both control subjects (p < 0.001) and patients with normoalbuminuria (p = 0.015) at peak exercise. There was a progressive worsening in gas exchange efficiency at the lungs, as measured by minute ventilation (VE)/carbon dioxide production (VCO(2)) at AT or DeltaVE/DeltaVCO(2) slope, (p = 0.006 and p = 0.019, respectively) going from control subjects to patients with normoalbuminuria and then to patients with microalbuminuria. Left ventricular ejection fractions and BP were similar in patients with normoalbuminuria and microalbuminuria. More patients with microalbuminuria (n = 9) than with normoalbuminuria (n = 2) demonstrated diastolic dysfunction (p = 0.013). These 11 patients had lower peak VO(2) values (p = 0.001) and higher daily UAE (p = 0.028). An inverse linear relationship was found between peak VO(2) and log(10) daily UAE (r = - 0.57, r(2) = 0.29, p < 0.001). CONCLUSIONS: Abnormalities reflecting reduced oxygen transport and impaired gas exchange efficiency were found during exercise, and were especially profound in patients with microalbuminuria. These changes could be secondary to pulmonary microangiopathy and myocardial interstitial changes. Increases in capillary permeability to proteins may take place in the myocardium as they do in the kidneys, and contribute to impaired myocardial distensibility and hence diastolic dysfunction.
Chun-Wing Lau A, So LK, Yam LY, Chan KS. Response to published article. J Infect. 2005 Oct 3; [Epub ahead of print]
So LKY, Lau ACW, Yam LYC. Chapter 9, Treatment of Severe Acute Respiratory Syndrome, in Kamps BS, Hoffmann C. SARS Reference, Flying publisher. www.sarsreference.com (Book Chapter)
ACW Lau, LKY So, LYC Yam. Chapter 10: Current Status of Therapy of SARS, in: Coronoviruses with Special Emphasis on First Insights Concerning SARS. Schmidt A, Wolff (vol eds) 2004, Birkhauser Publishers Ltd, Switzerland. (Book Chapter)
Arthur Chun-Wing LAU, Ida Kam-Siu, Man-Ching LI, Mary WAN, Alfred Wing-Hang SIT, Rodney Allan LEE, Raymond Wai-Hung YUNG, Loretta Yin-Chun YAM. Response to SARS as a prototype for bioterrorism: Lessons Learnt in a Regional Hospital in Hong Kong. Elsevier Scientific, Inc. (Book Chapter)
A series of 31 patients with probable SARS, diagnosed from WHO criteria, were treated according to a treatment protocol consisting of antibacterials and a combination of ribavirin and methylprednisolone. Through experience with the
first 11 patients, we were able to finalise standard dose regimens, including pulsed methylprednisolone. One patient recovered on antibacterial treatment alone, 17 showed rapid and sustained responses, and 13 achieved improvement with step-up or pulsed methylprednisolone. Four patients required short periods of non-invasive ventilation. No patient required intubation or mechanical ventilation. There was no mortality or treatment morbidity in this series.
A retrospective study was carried out in a Hong Kong regional hospital with 24-h emergency service, to study the factors associated with shorter time to re-admission after acute exacerbation of chronic obstructive pulmonary disease (COPD). From 1 January 1997 to 31 December 1997, the first admission (index admission) of each patient through the emergency room with COPD/chronic bronchitis/emphysema was included. A total of 551 patients fulfilled the inclusion criteria. The total acute and rehabilitative length of stay (mean +/- SD) was 9.41+/-11.67 days. Within 1 year after discharge, 327 patients (59 35%) were re-admitted at least once. Median time to first re-admission after discharge was 240 days. By Cox regression analysis, the following factors were independently associated with shorter time to re-admission: hospital admission within 1 year before index admission, total length of stay in index admission > 5 days, nursing home residency, dependency in self-care activities, right heart strain pattern on electrocardiogram, on high dose inhaled corticosteroid and actual bicarbonate level > 25 mmol l(-1). These factors may be relevant in the future planning of healthcare utilization for COPD patients.
Cheng F, Ip M, Wong KK, Yan WW.Critical care ethics in Hong Kong: cross-cultural conflicts as east meets west.J Med Philos. 1998 Dec;23(6):616-27. Comment in: J Med Philos. 1998 Dec;23(6):628-42.
The practice of critical care medicine has long been a difficult task for most critical care physicians in the densely populated city of Hong Kong, where we face limited resources and a limited number of intensive care beds. Our triage decisions are largely based on the potential of functional reversibility of the patients. Provision of graded care beds may help to relieve some of the demands on the intensive care beds. Decisions to forego futile medical treatment are frequently physician-guided family-based decisions, which is quite contrary to the Western focus on patient autonomy. However, as people acquire knowledge about health care and they become more aware of individual rights, our critical care doctors will be able to narrow the gaps between the different concepts of medical ethics among our professionals as well as in our society. An open and caring attitude from our intensivists will be important in minimizing the cross-cultural conflict on the complex issue of medical futility.