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Fulltext Validating a Lower Urine Output Criteria in predicting death in Critically Ill Patients

Azrina Md Ralib, Mohd Basri Mat Nor

International Medical Journal Malaysia, 2017;16(1):45-52.
MyJurnal

Urine output provides a rapid estimate for kidney function, and its use has been incorporated in the diagnosis of acute kidney injury. However, not many studies had validated its use compared to the plasma creatinine. It has been showed that the ideal urine output threshold for prediction of death or the need for dialysis was 0.3 ml/kg/h. We aim to assess this threshold in our local ICU population.
Fulltext Nutritional management of the critically ill obese patient

Mohd Basri Mat-Nor, Noor Airini Ibrahim, Fa’iza Abdullah

International Medical Journal Malaysia, 2018;17(2):143-148.
MyJurnal

Over the last decade, Malaysia has witnessed a steady rise in obesity rate. The overweight and obese now comprise of half its 30 million population. This figure is broken down into 30 percent in the overweight category and 17.7 percent in the obese category, according to the 2015 National Health and Morbidity Survey.1 This is an increase of four times from what was reported in 1996, at 4.4 percent.2 World Health Organization (WHO) definition of obesity is body mass index (BMI) of 30 or more, calculated as weight in kilograms divided by height in metres squared.3 As the general population get heavier, the average BMI of ICU admissions have also increased. From the International Nutrition Survey (INS) 2014, the average BMI of critically ill patients admitted to Serdang Hospital was 26 kg/m2 higher than the Asian average at 23.6 kg/m2 . 4 Being obese puts the patients at a greater risk of heart disease, hypertension, stroke, diabetes, sleep apnoea, fatty liver disease, osteoarthritis, and many other serious medical conditions.
Fulltext Satisfaction, Anxiety, Depression and Stress among Family Members of Patients in Malaysian Intensive Care Unit

Mohd Ariffudin Abdul Hamid, Mohd Basri Mat Nor

IIUM Medical Journal Malaysia, 2019;18(102):30-0.
MyJurnal

Family satisfaction has been identified as a quality indicator in critical care area. The impact of family satisfaction level was also found to be associated with symptoms of psychological distress such as anxiety, depression and stress among family members. We evaluated the satisfaction level and prevalence, risk factor and correlation of psychological distress symptoms with the satisfaction level among family members in Malaysian Intensive Care Unit (ICU). Materials and Method: This is a cross-sectional, multicentre study conducted in ICU at Hospital Sultanah Aminah Johor Bahru and International Islamic University Medical Centre. Family members were enrolled 3 days after ICU admission, and they completed a modified version of Critical Care Family Needs Inventory (CCFNI) and the Depression, Anxiety and Stress Scales (DASS). Results: A total of 176 family members were enrolled in this study. We found 116 (66%) of the family members scores ≥ 3 denoting satisfaction with the mean CCFNI score was 3.11 (SD=0.3). Prevalence of depression, anxiety and stress were of 30.1%, 41.4% and 28.9% respectively. Risk factor for psychological distress symptoms were female sex, spousal relationship, lower education, median income less than RM 4000, staying with patient and younger patient age. Negative correlation between depression, anxiety and stress with CCFNI score were found (p< 0.05) but with low correlation coefficient (r=-0.178 to -0.209). Family members without symptoms of psychological distress were more satisfied (higher CCFNI score) with ICU care compared to those with symptoms of psychological distress (p< 0.05). Conclusion: Family members of ICU patient were satisfied with the care provided in the ICU. High rates of psychological distress symptoms in this study and its correlation with the satisfaction level highlight the need to identify and implement preventive and management strategies for family members to improve the overall ICU care.
Fulltext Validation of the 28-day mortality prognostic performance of the modified Nutrition Risk in Critically Ill (mNUTRIC) score in a Malaysian intensive care unit

Wan Fadzlina Wan Muhd Shukeri, Samiullah Saeed, Azrina Md Ralib, Mohd Basri Mat-Nor

Malays J Nutr, 2019;25(4):413-421.
MyJurnal

Introduction: The mNUTRIC score is a nutritional assessment tool to identify critically
ill patients with high nutritional risk who could benefit from nutritional interventions.
This study was conducted to validate the 28-day mortality prognostic performance
of the mNUTRIC score in a Malaysian intensive care unit (ICU). Methods: This was
a retrospective cohort study of adult patients who were consecutively admitted to
the ICU from January 2017 to December 2018 for >24 hours. Data were collected on
variables required to calculate the mNUTRIC score. Patients with mNUTRIC score
≥5 points were considered to be at high nutritional risk. Main outcome was 28-
day mortality from all causes; ICU length of stay (LOS) and prolonged mechanical
ventilation (MV) (>2 days) were secondary outcomes. Results: From a total of 432
admissions, 382 (88.4%) patients fulfilled the study criteria. Seventy-seven (20.2%)
of these patients were at high nutritional risk. They had longer mean ICU LOS
(7.1±7.5 days versus 4.2±4.0 days, p=0.001), greater proportion of prolonged MV
(57.1% versus 14.4%, p
Fulltext The impact of fluid balances in the first 48 hours On mortality in the critically ill patients

Norhalini Hamzah, Majdiah Syahirah Nasir, Mohd Basri Mat Nor, Azrina Md Ralib

International Medical Journal Malaysia, 2016;15(1):13-18.
MyJurnal

Introduction: There has been increasing evidence of detrimental effects of cumulative positive fluid
balance in critically ill patients. The postulated mechanism of harm is the development of interstitial
oedema, with resultant increase morbidity and mortality. We aim to assess the impact of positive fluid
balance within the first 48 hours on mortality in our local ICU population. Methods: This was a secondary
analysis of a single centre, prospective observational study. All ICU patients more than 18 years were
screened for inclusion in the study. Admission of less than 48 hours, post-elective surgery and ICU
readmission were excluded. Cumulative fluid balance either as volume or percentage of body weight from
admission was calculated over 6, 24 and 48 hour period from ICU admission. Results: A total of 143 patients
were recruited, of these 33 died. There were higher cumulative fluid balances at 6, 24 and 48 hours in nonsurvivors
compared to survivors. However, after adjusted for severity of illness, APACHE II Score, they were
not predictive of mortality. Sensitivity analysis on sub-cohort of patients with acute kidney injury (AKI)
showed only an actual 48-hour cumulative fluid balance was independently predictive of mortality (1.21
(1.03 to 1.42)). Conclusions: Cumulative fluid balance was not independently predictive of mortality in a
heterogenous group of critically ill patients. However, in subcohort of patients with AKI, a 48-hour
cumulative fluid balance was independently predictive of mortality. An additional tile is thus added to the
mosaic of findings on the impact of fluid balance in a hetergenous group of critically ill patients, and in subcohort
of AKI patients.
Fulltext Augmented renal clearance in critically ill patients with sepsis: prevalence, risk factors and outcome

Shahir Asraf Abdul Rahim, Azrina Md Ralib, Abdul Hadi Mohamad, Ariff Osman, Mohd Basri Mat Nor

International Medical Journal Malaysia, 2017;16(11):15-15.
MyJurnal

Augmented renal clearance (ARC) is a phenomenon where there is elevated
renal clearance and defined by creatinine clearance more than 130ml/min. ARC results
in changes of the pharmacokinetic and pharmacodynamic of antimicrobial therapy being
administered, which may result in its subtherapeutic dose. We evaluated the
prevalence, risk factors and outcome of ARC in critically ill patients with sepsis. (Copied from article).
Fulltext Model-based insulin sensitivity for early diagnosis of sepsis in critical care

Wan Fadzlina Wan Muhd Shukeri, Azrina Md. Ralib, Ummu Khultum Jamaludin, Mohd Basri Mat-Nor

International Medical Journal Malaysia, 2017;16(11):9-9.
MyJurnal

Currently, it is almost impossible to diagnose a patient at the onset of
sepsis due to the lack of real-time metrics with high sensitivity and specificity. The
purpose of the present study is to determine the diagnostic value of model-based insulin
sensitivity (SI) as a new sepsis biomarker in critically ill patients, and compare its
performance to classical inflammatory parameters. (Copied from article).
Fulltext Sepsis mortality score using multi-marker approach for the prediction of mortality in septic critically ill patients

Wan Fadzlina Wan Muhd Shukeri, Azrina Md. Ralib, Mohd Basri Mat-Nor

International Medical Journal Malaysia, 2017;16(11):36-36.
MyJurnal

Clinical scoring methods such as the Sequential Organ Failure Assessment
(SOFA) score are frequently used to predict outcome in sepsis, with limited capacity.
Further tools for risk assessment of septic critically ill patients would thus be useful.
Our purpose was to derive a scoring method i.e. Sepsis Mortality Score using multimarker
approach for the prediction of 30-day mortality in septic critically ill patients,
and compare its performance to the SOFA score (Copied from article).
Fulltext Plasma Cystatin C and estimates of Glomerular filtration rate using Cystatin C independently diagnose acute kidney injury in critically ill patients with Sepsis

Azrina Md Ralib, Iqbalmunawwir Ab Rashid, Nur Aisyah Ishak, Suhaila Nanyan, Nur Fariza Ramly, Mohd Basri Mat Nor

International Medical Journal Malaysia, 2017;16(11):8-8.
MyJurnal

Plasma Cystatin C (CysC) is as an early functional marker for acute kidney
injury. Estimates of glomerular filtration rate using CysC (eGFRCysC) has been used in
some clinical setting. We evaluated the utility of CysC and eGFRCysC in diagnosing acute
kidney injury (AKI) and predicting death in critically ill patients with sepsis. (Copied from article).
Fulltext Estimates of Glomerular filtration rate by the chronic kidney disease epidemiology collaboration equations best correlates with kinetic estimates of Glomerular filtration rates in the critically ill

Azrina Md Ralib, Farah Nadia Mohd Hanafiah, Fatimah Dzaharudin, Muhammad Rasydan Abd Ghani, Mohd Nizamudin Ismail, Mohd Basri Mat Nor

International Medical Journal Malaysia, 2017;16(11):51-51.
MyJurnal

Kinetic estimate of GFR (keGFR) is a more accurate estimate of GFR in the
acute settings with rapidly changing kidney functions. It takes into account the changes
of creatinine over time, creatinine production rate, and the volume of distribution,
however needs serial measurement of creatinine. We evaluated which methods of the
conventional eGFR measurement best correlates with keGFR. This could assist clinicians
in using a simpler method of calculation and is useful in the absence of serial plasma
creatinine. (Copied from article).
Risk factors for mortality over 18 years in 317 ICUs in 9 Asian countries: The impact of healthcare-associated infections

Rosenthal VD, Jin Z, Rodrigues C, Myatra SN, Divatia JV, Biswas SK, et al.

Infect Control Hosp Epidemiol, 2023 Aug;44(8):1261-1266.
PMID: 36278508 DOI: 10.1017/ice.2022.245

OBJECTIVE: To identify risk factors for mortality in intensive care units (ICUs) in Asia.
DESIGN: Prospective cohort study.
SETTING: The study included 317 ICUs of 96 hospitals in 44 cities in 9 countries of Asia: China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam.
PARTICIPANTS: Patients aged >18 years admitted to ICUs.
RESULTS: In total, 157,667 patients were followed during 957,517 patient days, and 8,157 HAIs occurred. In multiple logistic regression, the following variables were associated with an increased mortality risk: central-line-associated bloodstream infection (CLABSI; aOR, 2.36; P < .0001), ventilator-associated event (VAE; aOR, 1.51; P < .0001), catheter-associated urinary tract infection (CAUTI; aOR, 1.04; P < .0001), and female sex (aOR, 1.06; P < .0001). Older age increased mortality risk by 1% per year (aOR, 1.01; P < .0001). Length of stay (LOS) increased mortality risk by 1% per bed day (aOR, 1.01; P < .0001). Central-line days increased mortality risk by 2% per central-line day (aOR, 1.02; P < .0001). Urinary catheter days increased mortality risk by 4% per urinary catheter day (aOR, 1.04; P < .0001). The highest mortality risks were associated with mechanical ventilation utilization ratio (aOR, 12.48; P < .0001), upper middle-income country (aOR, 1.09; P = .033), surgical hospitalization (aOR, 2.17; P < .0001), pediatric oncology ICU (aOR, 9.90; P < .0001), and adult oncology ICU (aOR, 4.52; P < .0001). Patients at university hospitals had the lowest mortality risk (aOR, 0.61; P < .0001).
CONCLUSIONS: Some variables associated with an increased mortality risk are unlikely to change, such as age, sex, national economy, hospitalization type, and ICU type. Some other variables can be modified, such as LOS, central-line use, urinary catheter use, and mechanical ventilation as well as and acquisition of CLABSI, VAE, or CAUTI. To reduce mortality risk, we shall focus on strategies to reduce LOS; strategies to reduce central-line, urinary catheter, and mechanical ventilation use; and HAI prevention recommendations.
Evaluating the outcome of a bundle with 11 components and the INICC multidimensional approach in decreasing rates of central line-associated bloodstream infections across nine Asian countries

Rosenthal VD, Yin R, Myatra SN, Divatia JV, Biswas SK, Shrivastava AM, et al.

J Vasc Access, 2024 Mar 27.
PMID: 38539085 DOI: 10.1177/11297298241242163

BACKGROUND: Central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs) across Latin America exceed those in high-income countries significantly.
METHODS: We implemented the INICC multidimensional approach, incorporating an 11-component bundle, in 122 ICUs spanning nine Asian countries. We computed the CLABSI rate using the CDC/NSHN definition and criteria. The CLABSI rate per 1000 CL-days was calculated at baseline and throughout different phases of the intervention, including the 2nd month, 3rd month, 4-16 month, and 17-29 month periods. A two-sample t-test was employed to compare baseline CLABSI rates with intervention rates. Additionally, we utilized a generalized linear mixed model with a Poisson distribution to analyze the association between exposure and outcome.
RESULTS: A total of 124,946 patients were hospitalized over 717,270 patient-days, with 238,595 central line (CL)-days recorded. The rates of CLABSI per 1000 CL-days significantly decreased from 16.64 during the baseline period to 6.51 in the 2nd month (RR = 0.39; 95% CI = 0.36-0.42; p
Decreasing central line-associated bloodstream infections rates in intensive care units in 30 low- and middle-income countries: An INICC approach

Rosenthal VD, Jin Z, Brown EC, Dongol R, De Moros DA, Alarcon-Rua J, et al.

Am J Infect Control, 2023 Dec 26.
PMID: 38154739 DOI: 10.1016/j.ajic.2023.12.010

BACKGROUND: Central line (CL)-associated bloodstream infections (CLABSIs) occurring in the intensive care unit (ICU) are common and associated with a high burden.
METHODS: We implemented a multidimensional approach, incorporating an 11-element bundle, education, surveillance of CLABSI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CLABSI rates and clinical outcomes, and performance feedback in 316 ICUs across 30 low- and middle-income countries. Our dependent variables were CLABSI per 1,000-CL-days and in-ICU all-cause mortality rates. These variables were measured at baseline and during the intervention, specifically during the second month, third month, 4 to 16 months, and 17 to 29 months. Comparisons were conducted using a two-sample t test. To explore the exposure-outcome relationship, we used a generalized linear mixed model with a Poisson distribution to model the number of CLABSIs.
RESULTS: During 1,837,750 patient-days, 283,087 patients, used 1,218,882 CL-days. CLABSI per 1,000 CL-days rates decreased from 15.34 at the baseline period to 7.97 in the 2nd month (relative risk (RR) = 0.52; 95% confidence interval [CI] = 0.48-0.56; P
Assessing the impact of a multidimensional approach and an 8-component bundle in reducing incidences of ventilator-associated pneumonia across 35 countries in Latin America, Asia, the Middle East, and Eastern Europe

Rosenthal VD, Jin Z, Yin R, Sahu S, Rajhans P, Kharbanda M, et al.

J Crit Care, 2024 Apr;80:154500.
PMID: 38128216 DOI: 10.1016/j.jcrc.2023.154500

BACKGROUND: Ventilator associated pneumonia (VAP) occurring in the intensive care unit (ICU) are common, costly, and potentially lethal.
METHODS: We implemented a multidimensional approach and an 8-component bundle in 374 ICUs across 35 low and middle-income countries (LMICs) from Latin-America, Asia, Eastern-Europe, and the Middle-East, to reduce VAP rates in ICUs. The VAP rate per 1000 mechanical ventilator (MV)-days was measured at baseline and during intervention at the 2nd month, 3rd month, 4-15 month, 16-27 month, and 28-39 month periods.
RESULTS: 174,987 patients, during 1,201,592 patient-days, used 463,592 MV-days. VAP per 1000 MV-days rates decreased from 28.46 at baseline to 17.58 at the 2nd month (RR = 0.61; 95% CI = 0.58-0.65; P 
Multinational prospective cohort study of rates and risk factors for ventilator-associated pneumonia over 24 years in 42 countries of Asia, Africa, Eastern Europe, Latin America, and the Middle East: Findings of the International Nosocomial Infection Control Consortium (INICC)

Rosenthal VD, Jin Z, Memish ZA, Rodrigues C, Myatra SN, Kharbanda M, et al.

Antimicrob Steward Healthc Epidemiol, 2023;3(1):e6.
PMID: 36714281 DOI: 10.1017/ash.2022.339

OBJECTIVE: Rates of ventilator-associated pneumonia (VAP) in low- and middle-income countries (LMIC) are several times above those of high-income countries. The objective of this study was to identify risk factors (RFs) for VAP cases in ICUs of LMICs.
DESIGN: Prospective cohort study.
SETTING: This study was conducted across 743 ICUs of 282 hospitals in 144 cities in 42 Asian, African, European, Latin American, and Middle Eastern countries.
PARTICIPANTS: The study included patients admitted to ICUs across 24 years.
RESULTS: In total, 289,643 patients were followed during 1,951,405 patient days and acquired 8,236 VAPs. We analyzed 10 independent variables. Multiple logistic regression identified the following independent VAP RFs: male sex (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.16-1.28; P < .0001); longer length of stay (LOS), which increased the risk 7% per day (aOR, 1.07; 95% CI, 1.07-1.08; P < .0001); mechanical ventilation (MV) utilization ratio (aOR, 1.27; 95% CI, 1.23-1.31; P < .0001); continuous positive airway pressure (CPAP), which was associated with the highest risk (aOR, 13.38; 95% CI, 11.57-15.48; P < .0001); tracheostomy connected to a MV, which was associated with the next-highest risk (aOR, 8.31; 95% CI, 7.21-9.58; P < .0001); endotracheal tube connected to a MV (aOR, 6.76; 95% CI, 6.34-7.21; P < .0001); surgical hospitalization (aOR, 1.23; 95% CI, 1.17-1.29; P < .0001); admission to a public hospital (aOR, 1.59; 95% CI, 1.35-1.86; P < .0001); middle-income country (aOR, 1.22; 95% CI, 15-1.29; P < .0001); admission to an adult-oncology ICU, which was associated with the highest risk (aOR, 4.05; 95% CI, 3.22-5.09; P < .0001), admission to a neurologic ICU, which was associated with the next-highest risk (aOR, 2.48; 95% CI, 1.78-3.45; P < .0001); and admission to a respiratory ICU (aOR, 2.35; 95% CI, 1.79-3.07; P < .0001). Admission to a coronary ICU showed the lowest risk (aOR, 0.63; 95% CI, 0.51-0.77; P < .0001).
CONCLUSIONS: Some identified VAP RFs are unlikely to change: sex, hospitalization type, ICU type, facility ownership, and country income level. Based on our results, we recommend focusing on strategies to reduce LOS, to reduce the MV utilization ratio, to limit CPAP use and implementing a set of evidence-based VAP prevention recommendations.

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