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Background We present a patient who received cerebral oximetry monitoring during targeted temperature management (TTM) post-cardiac arrest and discuss its potential in the early detection of cerebral hypoperfusion and implications on haemodynamics and ventilatory management. Case summary A 60-year-old Chinese male was admitted for acute pulmonary oedema with Type 2 respiratory failure. He failed an initial trial of non-invasive ventilation and was planned for intubation and mechanical ventilation. However, the patient suffered a pulseless electrical activity cardiac arrest peri-intubation. He was started on our institution’s protocolized post-cardiac arrest care bundle, which included cerebral regional oxygen saturation (rSO2) monitoring and TTM. Initial arterial blood gas (ABG) post-return of spontaneous circulation showed severe respiratory acidosis, and the patient was sedated, paralyzed, and ventilator settings optimized. Repeat ABG showed resolution of respiratory acidosis. However, a drop in rSO2 to 35% was subsequently noted. Ventilator settings were quickly adjusted, and dobutamine was started to improve global and cerebral perfusion. These measures improved cerebral rSO2 to more than 50%. Patient was cooled for 24 h and gradually rewarmed. He was later extubated with a cerebral performance category of 1 and is now on outpatient follow-up. Discussion During post-cardiac arrest care, there are many factors which can contribute to a decrease in cerebral blood flow. Therapeutic hypothermia and ventilation strategies, including the use of neuromuscular blocking agents, can both reduce pCO2 which is a major regulator of cerebrovascular tone. Accidental hypocapnia can lead to adverse cerebral vasoconstriction and hypoperfusion. Without cerebral oximetry, cerebral ischaemia may not be detected early and can potentially result in secondary brain injury.

Background: Poorly controlled diabetic patients (PCDP) are at increased risk during Ramadan fasting. International guidelines caution against Ramadan fasting among PCDP. However, many PCDP fast against medical advice. To our knowledge, no studies have specifically addressed the safety of Ramadan fasting by PCDP and hence, we aimed to study this. Methods: Adults with type 2 DM attending a tertiary hospital’s Endocrinology clinic, who had fasted for at least 2 weeks in Ramadan, were evaluated. The safety and biochemical parameters were compared between the 2 groups based on pre- Ramadan glycemic control-Group 1 (HbA1c Results: We evaluated 139 Ramadan fasts by 113 participant-70 fasts were by PCDP, of which 26 were studied twice (2016 and 2017). The results are summarised below. Hypoglycemia was more frequent in group 1 compared to PCDP (p = 0.017). However, there was no significant difference in other safety parameters between both groups. None of the PCDP suffered from hyperglycemia related complications. Conclusion: Most of the PCDP in our cohort were able to fast safely during Ramadan. Our findings need to be confirmed with prospective studies in different ethnic and geographic settings. PCDP with no prior hyperglycemic crisis can fast during Ramadan safely if specific education is offered and may even harness the beneficial effects of Ramadan such as metabolic memory. CharacteristicsGroup 1 (N = 69; mean HbA1c 7.8%)Group 2 (N = 70; mean HbA1c 10.8%)No. of days fasted (Mean)26.927.7Polydipsia (N)813Hypoglycemia (N)149Hyperglycemia (capillary blood glucose > 16 mmol/L, N)912Need to break fast due to hypoglycemia (N)149Need to break fast due to hyperglycemia (N)00Hyperglycemic crisis/ DM related hospital admissions (N)00Mean HbA1c change (%) pre and post-Ramadan+ 0.18- 0.28 Disclosure Y. Chee: None. S. Ng: None. K.J. Kwek: None. S. Abdul Shakoor: None.

Patient Initials or Identifier Number Mr LYC ### Relevant Clinical History and Physical Exam A 50 year old Chinese male presents with unstable angina and worsening dyspnea on exertion for 6 months. Cardiac risk factors include hypertension and hyperlipidemia. Clinical examination was