Situation 1

“Patient X admitted for NSTEMI. In the ward, he complained of mild chest discomfort, heavy in nature.” You planned to give SL GTN while planning to proceed with further investigations and management.

• Remember to check the blood pressure. GTN can cause hypertension

Situation 2

“Patient X admitted for symptomatic ascites secondary to decompensated liver cirrhosis.” You planned to do therapeutic peritoneal tapping to drain large amount of ascites.

• Remember to check vital signs (including blood pressure and pulse rate) before doing the procedure. We should not proceed with peritoneal tapping if the patient is unstable.
• Check vital signs again post procedure

Situation 3

“Patient X planned for femoral catheter insertion for urgent dialysis.” You planned to insert femoral catheter for the patient.

• Remember to check vital signs before and after procedures.

• Intubation / CPR / haemodialysis / operation / colonoscopy / OGDS etc. may not always work best for all patients.
• Sometimes comfort care is what the patient really needs.

Before any (invasive) intervention, we always counsel family members and patients regarding benefit VS harm (risks / complications including unnecsessary pain / bleeding) of that particular procedure. Usually we should avoid the ones that bring more harm than benefit.

How about in district hospital without specialist?
We can always consult the primary team (e.g. uro, surgery, medical, oncology etc.) for long term plan for that particular patient.

Situation A: Patient X with underlying prostate ca with metastasis deteriorated in ward -> intubated to secure secure airway -> updated to primary team (Uro) -> uro input was for comfort care, no active uro intervention and should not intubate the patient

Situation B: Patient X with underlying prostate ca with metastasis deteriorated in ward -> updated to primary team (Uro) -> uro input was for comfort care, no active intervention and should not intubate the patient -> patient not intubated -> patient still had some responses, which actually meant a lot to his/her family members

I believe Situation B would be better, if possible.

**Just some thoughts based on few cases that I’ve encountered before this.

Conclusion: Do the best for patients. But the best treatment is not always limited to those active intervention.

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Example / Illustration
SN: “Doktor, pesakit A SPO2 dia tak naik, 90% paling tinggi” (a patient admitted for AECOPD)
Doktor B: “Kita bagi high flow mask, aim SPO2 >95%”
1 hour later ….
SN: “Doktor, pesakit A mcm kurang respond dah” (Spirometer shows SPO2 95% under high flow mask)

In acute exacerbation of COPD, start with NPO2 or Venturi mask (e.g. VM35%) first instead of high flow mask. Excessive oxygen administration may lead to hypercapnic respiratory failure. (THE MORE OXYGEN YOU GIVE, THE MORE DROWSY THE PATIENT WOULD BE, and eventually resulting in CO2 narcosis)

Target SPO2 for patients with COPD would be 88 – 92%

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UNDERLYING MECHANISM
(I) V/Q mismatch: Excessive oxygen administration would increase V/Q mismatch and physiological dead space, subsequently causing hypercapnia. In COPD patients, poorly ventilated alveoli causes hypoxic vasoconstriction. However, excessive oxygen administration causes vasodilatation and increased blood flow (increased perfusion) to poorly ventilated alveoli, and causing increased V/Q mismatch.

(ii) Haldane effect: Oxygenated hemoglobin binds to carbon dioxide relatively poorly compared to deoxygenated hemoglobin, and thus deposits more carbon dioxide in the bloodstream (increased PaCO2). Normally rise in CO2 can be excreted through increased minute ventilation; but those with COPD are unable to increase their minute ventilation.

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OLD THEORY
Increased oxygen administration → loss of hypoxic drive → hypoventilation & type 2 respiratory failure ❌

Further reading:
1) GOLD COPD Pocket Guide 2021
2) https://litfl.com/oxygen-and-carbon-dioxide-retention-in-copd/

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Do not tocolyse women with placenta praevia (especially if bleeding) or abruptio placenta. Tocolytic agents (e.g. Nifedipine) will worsen haemodynamic compromise.

https://www.sciencedirect.com/topics/medicine-and-dentistry/tocolysis

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If placenta praevia in labour / bleeding placenta praevia + preterm, take note whether IM Dexamethasone had been served prior to this. If not yet given, to discuss with O&G Specialist KIV to start IM Dexamethasone.

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