Critical Care and Shock

Effect of Pacing Site on Global LV Performance Representative apneic steady state LV pressure-volume relations during baseline RA, RV, CRTa and CTRfw with their respective end-systolic pressure-volume relations superimposed as straight lines.
Effect of Uni-LV and BiV Pacing on LV Pressure-Volume Relations Comparison of RA-LV with RA-RV-LV (CRT) pacing on LV pressure volume relations for LV free wall (left) and apical (right) sites. Note that RA-LV pacing produces LV pressurevolume histories similar but not identical to their respective CRT pacing pairs and quite distinct from the RA pacing alone. Abbreviations as in Figure 1.
Effect of Pacing Site on Maximal Contraction Delay Mean±SD time to maximal strain across all regions for all animal (n=8) for RA, RA-RV, CRTa and CRTfw during baseline and esmolol-induced beta adrenergic blockade conditions. Abbreviations as in Figure 1
BACKGROUND: Quantification of left ventricular (LV) dyssynchrony allows for objective measures of resynchronization therapy (CRT) effectiveness. We tested the hypothesis that site of LV pacing, fusion beats and baseline contractility alter contraction synchrony as quantified by regional and global measures of LV performance. METHODS AND RESULTS: In 8 open-chested pentobarbital-anesthetized canine preparations we compared the effects of right atrial (RA), RA-high right ventricular (RV) free wall, as a model of left bundle branch block contraction pattern, RA-LV apex (LVa), RA-LV free wall (LVfw), and RA-RV-apical LV (CRTa) and RA-RV-free wall LV (CRTfw), as CRT. LV pressure-volume loops recorded using high-fidelity pressure and conductance catheters and echocardiographic angle-corrected color-coded strain imaging of mid-LV short axis views analyzed radial strain from six segments. To control for contractile state esmolol-induced beta blockage was studied, and in 5 dogs to control for RA and ventricular pacing fusion beat artifacts, repeat studies were done following AV node ablation. RA-RV pacing reduced stroke work (SW) (57±18 to 33±13* mmHg·mL,*p<0.05 vs RA pacing), decreased LV end-diastolic volume and induced marked radial dyssynchrony (maximal time difference between peak segmental strain) from 31±15 to 234±60* ms. Changes in radial dyssynchrony correlated significantly with changes in SW (r=-0.53, p<0.01). Dyssynchrony improved with both CRTa and CRTfw (69*±31 and 98*±63 ms, respectively) while SW only improved with CRTa (62±22* and 37±13 mmHg·mL, respectively * p<0.05 vs RV pacing). CRTa also tended to increased LV end-diastolic volume over RA-RV. Esmolol slowed HR from 118±10 to 108±10 beats/min* and tended to decrease contractility (end-systolic elastance (Ees) from 12.1±7.9 to 8.9±3.9 mmHg/ml, p=0.167) but did not alter the degree of RV-pacing induced dyssynchrony. AV ablation had no effect on the observed apical and free wall contraction differences seen during baseline conditions. CONCLUSION: Although both CRTa and CRTfw reduced contraction dyssynchrony, CRTa tended to improve global LV performance more by increasing end-diastolic volume. Thus, CRT may improve global LV performance differently, depending on the LV pacing site.
The objective of the study is to determine factors that influence the outcome of long stay patients in a general intensive care unit (ICU) and/or high-dependency unit (HDU) in a New Zealand teaching hospital. 10-bed general ICU and 4-bed surgical HDU in a 400-bed hospital. Population based retrospective cohort study. All patients with prolonged stay in a high resource area (>7 days in the ICU or >14 days in either the ICU or HDU) between 2000 and 2003 were reviewed. Demographic data, co-morbidities, diagnoses, clinical events, hospital and 1-year mortality data were obtained using available databases and patient records. Multiple logistic regression analysis was performed to identify which variables are associated with death among patients with a prolonged stay in a high-resource unit (ICU/HDU). 207 patients were included in the study. Twenty eight percent died before hospital discharge and 40% died within one year of their admission. Univariate analysis showed that increasing age, APACHE II score, admission post cardiac arrest, inpatient cardiac arrest, development of sepsis and requirement for renal support therapy were all risk factors for increased mortality. However, when adjusted for age, gender and APACHE II score the only risk factor strongly associated with death was having a cardiac arrest in the ICU. Prolonged ICU and/or HDU stay is associated with a high mortality rate particularly in patients with advancing age and increasing severity of illness. In this study, only cardiac arrest after a prolonged stay in the ICU and/or HDU is a strong predictor of death independent of the age and the APACHE II score.
Interleukin 11 (IL-11) and stem cell factor (SCF) stimulate platelet production. In this study, we examined serum IL-11 and SCF levels in 4 patients with disseminated intravascular coagulation (DIC) complicating massive trauma and infections. The serum concentrations of both IL-11 and SCF showed a marked increase coinciding with the development of DIC in these patients, regardless of the presence or absence of infections. Further studies are required to confirm whether the increase in levels of these two platelet-inducing cytokines with the onset of DIC reflects an enhancement of platelet production in order to maintain the biological system in balance, or simply an inflammatory biological response.
Objective: This study aims to determine the correlation between elevated tumor necrosis factor alpha (TNF-α) and syndecan-1 with urine interleukin (IL)-18 levels as post-cardiac surgery-related acute kidney injury (AKI) marker. Design: This study was an analytical observa-tional study with a cross sectional design. Setting: This study was conducted at Dr. Wahi-din Sudirohusodo Central General Hospital. The period of study was from October 2019 to February 2020. Patients and participants: Population of study was all patients who underwent adult on pump cardiac surgery. Study samples were patients who were included in inclusion criteria. Pa-tient’s characteristics were presented as fre-quency and percentage. Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Spearman correlation test was performed to determine the correlation between TNF-α, syndecan-1, and IL-18 levels toward AKI inci-dence. The data was presented with odds ratio (OR) 95% confidence interval (CI). There were 33 subjects who underwent adult cardiac surgeries including coronary artery bypass grafting (CABG), valve, and congenital disorder surgeries. Twenty-one people (63.6%) had AKI and 12 people (36.4%) did not. In AKI patients there was an increased syndecan-1 level of 61.94±36.58 ng/ml with relative risk (RR)=1.11 (95% CI 1.02-1.21), TNF-α level of 6.85±4.05 pg/ml, RR=2.61 (95% CI 1.19-5.71), and IL-18 level of 205.5±121.35 pg/ml, RR=1.38 (95% CI 1.06-1.79). There was a significant correlation between syndecan-1, TNF-α, and IL-18 levels. AKI incidence in post-cardiac surgery patients had a significant elevated IL-18 level (p=0.016), with RR=1.38 (95% CI 1.06-1.79). Conclusion: Elevated syndecan-1, TNF-α, and IL-18 levels were correlated with AKI incidence in post-cardiac surgery patients. © 2021, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Chest CT obtained on hospital admission shows bilateral ground glass opacities seen predominantly in the right lower lobe
In December 2019, a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of respiratory disease in Wuhan, China, that quickly spread to other countries causing a global pandemic. Although the reverse transcriptase polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection has become the standard method of diagnosis, this test has limitations that cause false negative results. The sudden onset, and spread of this virus, has created an urgency to find reliable screening and diagnostic tools to identify infect ed patients, prevent further transmission, and provide treatment for these patients. A rapid and accurate diagnostic tool, the COVID-19 combined IgG and IgM “Rapid” test can detect these antibodies against SARS-CoV-2 using a finger prick blood sample detecting infection in 15 minutes. We report the use of the COVID-19 IgM Rapid Test in the presence of high clinical suspicion, along with typical chest computed tomography findings suggestive of COVID-19 infection, in a patient who tested negative twice for the nasopharyngeal swab specimen RT-PCR test. © 2020, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Objective: We aimed to describe the characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit (ICU) in Portugal. Design: This is an observational retrospective study. Demographic and clinical data were col-lected. Respiratory failure treated with invasive mechanical ventilation (IMV) and death during ICU stay were the main outcomes evaluated. Setting: This study was conducted in the Infectious Diseases ICU of Centro Hospitalar e Uni-versitário de São João, in Porto, Portugal, be-tween March 11 and August 17, 2020. Patients and participants: All consecutive patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infec-tion, admitted to the ICU during the study peri-od were enrolled, and 62 patients were included. Measurements and results: The median age was 71 years (IQR, 54-78) and 39 (62.9%) were male. Thirty-four (54.8%) patients received. IMV in contrast to 28 (45.2%) who were not intubated and the median lowest PaO2/FiO2 was 86 (IQR, 70-113) in IMV and 150 (94-257) in non-IMV patients. Several patients with severe hypoxemic COVID-19 were treated without IMV, especially with high flow nasal cannu-la (HFNC). Overall mortality was 21.8% and older age, male sex, active cancer, lower lym-phocyte count, higher aspartate aminotransfer-ase (AST) level, and higher creatinine level at admission, hematologic dysfunction, and renal dysfunction during ICU stay were all associated with fatal outcome. Mortality was lower than observed in other series of critically ill patients, although comparisons are limited by different ICU admission criteria, management practices, and duration of follow-up. Conclusions: This study provides data regard-ing the characteristics and outcomes of COVID-19 critically ill patients that can be used to op-timize ICU preparedness in the future. © 2021, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Introduction: Risk factors for mortality of critically ill Coronavirus disease 2019 (Covid-19) were older age, use of a mechanical ventilator, high modified nutrition risk in critically ill (mNUTRIC) score, presence of comorbidities, lower body mass index (BMI), acute respiratory distress syndrome (ARDS), and energy deficit in an intensive care unit (ICU). Methods: A retrospective cohort study was conducted in the ICU of Dr. Kariadi Central Hospital, Semarang, Indonesia from March to December 2020. Subjects were adult, confirmed Covid-19 patients, stayed in the ICU for 3 days or more. Secondary data collected were demographic and anthropometric data, respiratory support, comorbidity, partial pressure of oxygen (PaO2) to the fraction of inspired oxygen (FiO2) ratio, mortality, body mass index (BMI), mNUTRIC. score, route of nutrition delivery, and energy deficit. Cut-off points for energy deficit at days 3, 5, and 7 were determined by the receiver operating characteristic (ROC) curve. The calculation for relative risk followed by multiple logistic regression analysis measured risk for mortality. Result: A total of 112 patient data were analyzed. Most subjects were male, aged <60 years old, had at least 1 comorbidity, had moderate or severe ARDS. The mortality rate was 50.9%. An energy deficit of 2000 kcal at day 3, 2975 kcal at day 5, and 3750 kcal at day 7 yielded a relative risk of 8.2, 6.6, and 2.5, respectively. The degree of ARDS, the use of mechanical ventilator, mNUTRIC score, and comorbidity were also significantly associated with mortality. Conclusion: Energy deficit at the first week of ICU stay was a significant risk factor for mortality in critically ill Covid-19 patients. © 2022, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
The use of therapeutic hypothermia (TH) in clinical medicine is no longer a rarity. Since the modern inception of this technique by Fay in the 1940s, TH has been used for a variety of clinical scenarios. (1,2) TH has gained signifcant popularity as a brain-protection strategy in victims of sudden cardiac death in whom return of spontaneous circulation (ROSC) has been obtained with coma. (3) Nonetheless, many trials and case series have shown the advantageous effects of lowering the body's core temperature in a variety of other clinical conditions including near-drowning, hypoxemic brain injury, traumatic brain injury, traumatic cardiac arrest, stroke, newborn hypoxic-ischemic encephalopathy, hepatic encephalopathy, bacterial meningitis, congestive heart failure, postoperative neonatal tachycardia, and the acute respiratory distress syndrome. (2,3) However, despite the well documented evidence of its therapeutic value, and the ease of implementation, TH is not used as much as the authors would envision for such a cardiopulmonary and cerebral cornerstone of advanced cardiac life support. (4) In this issue of Critical Care and Shock, two articles present encouraging data on the use of this therapeutic intervention in the context of cardiovascular conditions in two different countries. Palo and associates, report on their experience in a tertiary care center in the Philippines, utilizing TH within 6 hours of a cardiac arrest with successful return of spontaneous circulation (ROSC) and coma. (5) These investigators found a direct correlation between neurological outcome and the implementation of TH.
Objective: The high mortality rate found on infectious patients in the intensive care unit (ICU) calls for sepsis identification tools. Sepsis consensus introduced Systemic Inflammatory Response Syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA) score, and Sequential Organ Failure Assessment (SO-FA) score. This study aimed at comparing the accuracy and quality to discriminate among the SIRS, qSOFA score, and SOFA score for predicting mortality among patients at risk of sepsis admitted to the ICU. Design: This study used the analytic observational method with retrospective cohort approach to a sample of 73 qualified medical record data. The data regarding the SIRS, qSOFA, and SOFA criteria were applied after 24 hours of ICU admission. Setting: ICU of Dr. Hasan Sadikin General Hospital, Bandung from January to December 2017. Measurements and results: The results of this study showed the SOFA score as being the most accurate and having a good quality to discriminate, with the value of area under the receiver operating characteristic (AUROC) 0.866 (95% CI 0.782-0.95; p=0.00); the qSOFA score had AUROC of 0.707 (95% CI 0.588-0.826; p=0.002) while SIRS criteria were not significant. Conclusions: The conclusion of this study is that in patients with suspected sepsis admitted to an ICU, the SOFA score is the most accurate to predict mortality, whereas qSOFA could be considered and the SIRS criteria is not recommended. © 2019, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Background: The aim of this experimental study was to examine the effect of the antioxidant drug "U-74389G" testing, on rat model and particularly in an ischemia reperfusion (IR) protocol. The beneficial effect or non-effectiveness of that molecule was studied biochemically using mean blood sodium levels. Material and methods: 40 rats of mean weight 231.875 g were used in the study. Sodium levels were measured 60 min after reperfusion (groups A and C) and 120 min (groups B and D) after reperfusion with administration of the drug "U-74389G" in groups C and D. Results: "U-74389G" administration non-significantly increased the sodium levels by 0.25 mmol/l (-1.479487 mmol/l-1.979487 mmol/l, p=0.7714). This finding was in accordance with the results of paired t-test (p=0.7714). Reperfusion time significantly decreased the sodium levels by 0.4636364 mmol/l (-1.496569 mmol/l- 0.5692967 mmol/l, p=0.3693). Conclusions: "U-74389G" administrations as well its interaction with reperfusion time have non-significant alteration short-term effects on sodium. Perhaps, longer experiment times may reveal any possible significant effect of "U- 74389G" on blood sodium levels.
Introduction: Intra-abdominal hypertension is now well recognized in intensive care patients. Increasing knowledge of the incidence, causes, pathophysiology and outcome of intra-abdominal hypertension has resulted in earlier and more definitive management of the condition in the last decade. Although these advances appear to have improved outcome, many issues remain controversial. Methods: A literature review of relevant papers was conducted. Conclusions: The incidence of intra-abdominal hypertension varies widely depending on the intra-abdominal pressure used to define the condition and the sub-group investigated. Monitoring intra-abdominal pressure by measuring urinary bladder pressure is simple and sufficiently accurate. It has been suggested that intra-abdominal hypertension occurs when intra-abdominal pressure exceeds 1O to 12mmHg. Abdominal compartment syndrome is a severe form of intra-abdominal hypertension and occurs when intra-abdominal pressure exceeds 20-25mmHg and associated organ failure is evident. Intra-abdominal hypertension has potentially damaging effects on the gastrointestinal, cardiovascular, renal, respiratory and central nervous systems. There is an association between intra-abdominal hypertension and multiple organ failure, but causation has not yet been convincingly shown. Expert consensus suggests that an acute increase of IAP to above 20-25mmHg and/or evidence of abdominal compartment syndrome is an indication for surgical decompression.
Objective: To avoid the misinterpretation of electrocardiogram (ECG) abnormalities in acute intracerebral hemorrhage (ICH), it is important to recognize ECG abnormalities in such patients. Previous studies have reported ECG disorders in ICH patients based on a single ECG tracing. In this study, we used ECG Holter monitoring to determine ECG abnormalities in acute ICH patients. Methods: This was a prospective analysis of acute (up to 24 hours following admission) nontraumatic ICH patients who were admitted to our hospital between January 2014 and April 2015. Initially, an ECG and cerebral computed tomography (CT) scan were obtained within the first day of admission. The patients then underwent ECG Holter monitoring for 24 hours. Finally, the ECG abnormalities and their association with the CT scan findings were analyzed. Results: This study included 108 patients with acute non-traumatic ICH. The most frequent ECG abnormalities shown by Holter monitoring were ectopic beats (85.2%), followed by sinus tachycardia (63.2%). Only the presence of midline shift on the CT scan had a significant correlation with ectopic beats (OR: 1.3, CI: 1.05-1.7). Conclusion: ECG Holter monitoring in 108 acute ICH patients demonstrated a correlation between the presence of midline shift on the cranial CT scan and ectopic beats in the ECG Holter monitoring. © 2018, Indonesian Society of Critical Care Medicine. All rights reserved.
Psychomotor disturbance in Intensive Care Unit (ICU) continues to be a challenging issue in view of its various ranges of predisposing factors and this includes withdrawal from chronic substance abuse. A combination of opioids, benzodiazepines and antipsychotics are often used to treat such neurochemical disturbances. We report a case of 43 year-old man with 10 years history of substance abuse who presented with acute opioids intoxication. He required mechanical ventilation but exhibited significant agitation in the ICU. The conventional combination of midazolam and morphine, and later propofol infusion failed to control his agitations following admission. However, his symptoms improved and he was extubated within the first 24 hours of stay after dexmedetomidine infusion.
Purpose: To describe the successful endovascular treatment using direct carotid artery access in a high risk elderly patient with symptomatic internal carotid artery stenosis. Case Report: A 98 year-old man who was independent and lived alone was admitted to our hospital for symptoms of progressive weakness, associated with disorientation and difficulty with speech. Duplex carotid ultrasound was performed which revealed a totally occluded right internal carotid artery and high grade stenosis of the left internal carotid artery. Because of his advanced age he was deemed to be at high surgical risk for a standard endarterectomy, thus he was referred for carotid artery stenting. Using the femoral artery approach, multiple guiding catheters and sheaths were advanced to the left common carotid artery. Adequate support for intervention could not be obtained. The procedure was aborted and the patient was referred for carotid endarterectomy However, due to his advanced age, he felt that surgery was too high risk thus he chose an alternative attempt to endovascular carotid stenting.Therefore, he was brought back to the catheterization laboratory two days later for direct carotid access. Carotid artery stenting was accomplished with a 6F sheath, a cerebral protection device and a Nitinol stent all percutaneously via the left common carotid artery. The patient was discharged the following day without complications. At 3-month follow-up, the patient is functional and independent without recurrence of symptoms. Conclusion: Direct carotid access can be successfully accomplished in patients if the femoral artery approach is anatomically prohibitive. In those of advanced age or other high risks for surgery, direct carotid access can be considered an option for revascularization.
Objective: Spectrophotometric hemoglobin (SpHb) monitoring is a new noninvasive technology for measuring hemoglobin (Hb). However, few studies have assessed the usefulness of the initial screening SpHb values, especially when measured in an Emergency Department. In this study, we examined the correlation between the initial screening SpHb values and laboratory-measured hemoglobin (Hb) concentrations. Design: This was a retrospective, single center study. Setting: Emergency Department in a University hospital. Patients: 105 cases between February and July 2016. Interventions: The correlation between SpHb and Hb was determined in univariate analysis. Multiple regression analysis was then performed with ?Hb (defined as the absolute difference between SpHb and Hb [|SpHb-Hb|]) as the dependent variable to identify factors associated with reduced accuracy of SpHb. Results: The initial screening SpHb value was only moderately correlated with Hb in univariate analysis (r=0.736, p<0.001). In multiple regression analysis, male sex and diastolic blood pressure were significantly associated with ΔHb (p=0.003 and p=0.022, respectively). Conclusions: The initial screening SpHb value was only moderately correlated with Hb. SpHb might affected by patient factors, including male sex and diastolic blood pressure. © 2017, Indonesian Society of Critical Care Medicine. All rights reserved.
Adequate fluid resuscitation is still a major treatment to optimize hemodynamics and to restore organ perfusion in the case of volume depletion. To achieve this goal, a wide variety of fluids are available to the clinician. Due to their different composition, the usual classification opposites crystalloids and colloids. Despite numerous studies, controversy still exists on the ideal fluid resuscitation. The trend to choose preferentially one or another during the last century has moved just like a pendulum. Acidosis as a consequence of fluid replacement is well known since more than 80 years ago. Initially, according to the classical Henderson-Hasselbalch approach, this disturbance was simply explained by a phenomenon of plasma bicarbonate dilution which was responsible for a proportional decreased pH. Consequently, acidosis has been called "dilutional acidosis". But, in the 1970s, Stewart described a new concept for the interpretation of acid-base equilibrium. In this approach, pH variations result from changes in 3 independent variables which are the strong ion difference (SID), the total charge in weak acids and the PaCO2. This concept emphasizes the implication of chloride and weak acids in acid-base equilibrium. Considering this approach, it is clear that the infusion of fluids containing high concentration of chloride leads to hyperchloremic metabolic acidosis. In this way, acidosis is not related to a simple dilution, but to the decreased SID which results totally from hyperchloremia. According this concept, crystalloids and colloids are now sub-classified into balanced or unbalanced categories. Balanced solutions are those that contain a concentration of chloride close to that of the plasma, whereas the unbalanced fluids are those characterized by a proportional high chloride concentration. Since about 10 years ago, normal saline, an unbalanced solution, remains the most popular choice of IV fluid. Due to its preferential administration, hyperchloremic metabolic acidosis is more and more frequently observed during the perioperative period and in critically ill patients. Numerous experimental and clinical trial have confirmed this phenomenon. Finally, whatever the exact mechanism, iatrogenic hyperchloremic metabolic acidosis produced by unbalanced expanders is now demonstrated. But, the real question is about the clinical relevant of potentially harmful effect of these changes, especially of hyperchloremia. Actually, the answer is not univocal. Only short-term infusion of unbalanced fluids has been studied, so that, only slight and transient hyperchloremic metabolic acidosis are described. Nevertheless, some recent data support transient postoperative cerebral, renal or digestive dysfunction in patients with hyperchloremia. A worsen outcome and a shorter survival time have been also found in experimental septic rats, long-term resuscitated with unbalanced solutions. However, these results need to be confirmed by further prospective randomized clinical trial of clinical outcome. In other words, present data which are still essentially biological modifications, cannot permit objectively to avoid totally or partially volume expansion with unbalanced solutions.
Severe sepsis is common in intensive care and has a high associated mortality. A recent breakthrough among the novel therapies is the use of intravenous recombinant human activated protein C Xigris™ (drotrecogin alfa activated) which reported a 19.4 percent reduction in the relative risk of death at 28 days. This is translated to 1 additional life saved for every 16 patients treated with drotrecogin alfa activated by 28 days, considerably lower than the number needed to treat of 56 to prevent one death by 35 days for intravenous thrombolytic treatment in acute myocardial infarction-a widely accepted benchmark of effective clinical practice. We described our initial experience with Xigris in 4 patients who were admitted to our intensive care unit (ICU) for severe sepsis. All patients were ventilated and had Acute Physiology and Chronic Health Evaluation (APACHE) II scores equal or greater than 25. Three out of 4 were discharged alive from ICU and there was no serious bleeding complication.
Spinal cord injury (SCI) is a serious condition that produces lifelong disabilities, with only limited therapeutic measures currently available. The incidence of SCI in the United States is estimated to be 30-40 cases per one million inhabitants, with resultant in-hospital mortality of 20 to 52 percent. (1,2) Traumatic SCI is followed by a progressive injury process that involves various pathophysiological events that lead to tissue destruction. Although the mechanisms are not fully understood, progressive vascular events, such as ischemia/reperfusion-induced endothelial damage, are involved in this process. As in sepsis, studies have demonstrated that activated neutrophils are important in inducing the damage to endothelial cells. (3) A common complication in patients with SCI is sepsis, which is associated with acute organ dysfunction, and results in a generalized inflammatory and procoagulant state. Sepsis is a major cause of death in intensive care units worldwide, with mortality rates that range from 20% for sepsis to 40% for severe sepsis to >60% for septic shock, that if related to SCI may be aggravated with concomitant spinal shock. We describe our experience with recombinant human activated protein C (rhAPC) in patients with SCI and severe sepsis (SS).
Sepsis and septic shock are responsible for substantial morbidity and mortality in the intensive care units. NF-κB, macrophage migration inhibitory factor (MIF), tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1), IL-6, reactive oxygen species, inducible nitric oxide (iNO), oxidized phospholipids, and eicosanoids play a significant role in the pathogenesis of sepsis and septic shock. Conversely, adenosine, activated protein C, oxidized phospholipids, ω-3 fatty acids, some inducible cyclo-oxygenase products, and insulin show anti-inflammatory actions and have beneficial effects in sepsis and septic shock. Hence, it is suggested that combined use of some of these naturally occurring and endogenous anti-inflammatory compounds may be of significant benefit in sepsis and septic shock.
Oliguria is common in critically ill patients, the most common cause being a reduction of the effective intravascular volume. Oliguric patients are almost universally treated with escalating doses of loop diuretics in the hope of increasing urine output. However, in the setting of a reduced effective intravascular volume loop diuretics cause a marked fall in glomerular filtration rate with an acute decline in renal function. In this paper we demonstrate that there is no scientific rationale or clinical evidence to support the use of loop diuretics in patients with oliguria and pre-renal azotemia, prophylactically in patients at risk of developing acute renal failure and in patients with established acute renal failure.
Objective: Transfusion-related acute lung injury (TRALI) is a relatively uncommon complication in patients who undergo plasma-containing blood product transfusion. Despite the cross matching process, TRALI remains the most common cause of mortality associated with transfusion. We describe a case of TRALI in a 24-year-old trauma patient who was successfully cared for on extracorporeal membrane oxygenation (ECMO). Design: Chart review. Setting: Academic medical center with Level 1 Trauma. Patients and participants: Single case from a busy urban trauma center. Interventions: Extracorporeal membrane oxygenation. Conclusion: ECMO has only rarely been successfully used in patients with TRALI; to our knowledge, ours is the first successful report of its use in a trauma patient. Its use in maintaining gas exchange in trauma patients with TRALI should be further investigated.
Resuscitation incoherence is a mismatch between macrocirculation, microcirculation, and cellular parameters after resuscitation. We report a 34-year-old obese male patient, suffering from end-stage renal disease or chronic kidney disease (CKD), underwent routine hemodialysis three times a week and hypercoagulability state with rivaroxaban therapy. He had a cardiac arrest during kidney transplant surgery. Acute right heart failure causing cardiac arrest was presumably caused by acute intraoperative pulmonary embolism. Hemodynamic and resuscitation incoherence occurred and proper treatment was needed. At the time of cardiac arrest, hemodynamic coherence was lost and resuscitation was performed to restore this loss by correcting the possible causes of cardiac arrest. Although the return of spontaneous circu. lation (ROSC) was successfully achieved, a type 1 resuscitation incoherence occurred where the macrocirculation was optimal but cellular parameters were disturbed by cell hypoxia, characterized by high levels of lactate. Type 2 resuscitation incoherence was also found in this patient until the end of treatment in the intensive care unit (ICU). Cellular parameters such as lactate levels and the venoarterial carbon dioxide tension difference to arteriovenous oxygen content difference ratio (P[v-a]CO2)/(C[a-v]O2) continued to improve during ICU treatment, but cell hypoxia might occur since the central venous pressure (CVP) value as a macrocirculation parameter was likely to increase, presumed to be caused by incomplete resolved acute pulmonary embolism related chronic thromboembolic pulmonary hypertension. © 2020, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Ultrafiltration by continuous venovenous hemofiltration (CVVH) is a well-established therapy for acute decompensated heart failure (ADHF). Aggressive fluid removal, however, may worsen the symptoms or even inflict de novo organ dysfunctions especially in the hemodynamically unstable patients. We described the incorporation of CVVH and impedance cardiography (ICG) in the management of an ADHF patient on maintenance hemodialysis. Simultaneous monitoring of the hemodynamic and fluid status using ICG helped optimize the CVVH prescription and improve the patient outcome. As such, assessment of the unique hemodynamic characteristics of each critically ill patient is indispensable, which may enhance the efficiency of the critical care unit. Selection of the ultrafiltration against diuretics is also discussed.
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-fve patients were included in the fnal 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.
The management of acute pancreatitis depends on the evaluation of its severity, mainly based on multiparameter scores such as Ranson score. Patients with mild or moderate acute pancreatitis are characterized by a spontaneous recovery and do not require enteral or parenteral nutrition. Patients with severe pancreatitis need a nutritional support. According to present data, enteral nutrition should be preferred to parenteral nutrition. Parenteral nutrition should be used in cases with prolonged ileus, when patient do not tolerate enteral nutrition and when enteral nutrition is not unable to satisfy nutritional requirements. Energy requirements vary between 25 and 35 kcal/kg/day. It is recommended to start with 15 to 20 kcal/kg/day in patients with multi-organ failure. Glucose supply should be 3 to 6 g/kg/day, if necessary associated with insulin in order to maintain blood concentrations < 10 mmol/l. Fat is well tolerated in the absence of hypertriglyceridemia. As in other stress conditions, a fat supply representing 30% of non-protein energy has been recommended. Protein requirements have been estimated at 1.2-1.5 g/kg/day. Vitamins and trace-elements should be integrated to nutritional support during severe pancreatitis with special attention to vitamins A, C, E, zinc and selenium.
Murine typhus is a flea-borne, worldwide rickettsial disease caused by Rickettsia typhi. It is typically a mild illness, which clinical features include fever, rash, and headache, but sometimes it is fatal. Recently, we experienced 5 cases of ARDS associated with a Rickettsia typhi infection. These cases were not suspicious initially, but later they were proven by high titers of serum IgG antibodies (1:512 or higher) with the IFA method. All 5 patients had no rash. Three of them live in urban areas. Murine typhus would be one of the etiologies for ARDS of unknown causes, especially in an endemic region.
Chest radiography on admission showed bilateral alveolar infi ltrates
Diffuse alveolar hemorrhage (DAH) is a life-threatening condition that complicates various clinical entities. While mitral stenosis is a well-known cardiovascular cause, acute mitral regurgitation (MR) related DAH is rarely reported. We report a patient with a stormy course of acute MR induced DAH with concomitant Coomb's negative intravascular hemolysis, which resolved completely after mitral valve surgical repair.
Acute Postobstructive Pulmonary Edema (APOPE) is rare form of non-cardiogenic pulmonary edema. APOPE is a manifestation of acute airway obstruction usually described following anesthesia in post-operative phase due to laryngospasm. We present a case of 58 yearold lady who developed a severe APOPEinduced by a massive thyroid goiter. The subsequent imaging studies revealed the compressing mass-effect of the thyroid goiter on the upper airway. The prompt recognition of this rare clinical event is crucial to rapidly restore the patency of the airway and correct hypoxemia.
A 63 year-old gentleman with a history of mitral valve repair and recent travel to the Philippines presented to our hospital with complaints of dry cough for three days. His clinical exam was remarkable for diffuse rhonchi. Initial chest radiograph was non-revealing. The patient clinical condition deteriorated in the emergency department (ED) with rapidly progressive respiratory insufficiency and interval development of radiographic infiltrates (Figure 1). The patient was then admitted to the intensive care unit (ICU) and broad-spectrum antibiotics started. As the patients' symptoms and radiological findings worsened bronchoscopy and bronchoalveolar lavage were emergently performed. The later yielded no organisms. A transbronchial biopsy was non diagnostic. An open lung biopsy was performed and consistent with bronchiolitis obliterans organizing pneumonia (BOOP). Again, all cultures were negative and no organisms seen. The patient was started on intravenous corticosteroids with and excellent clinical response and two days later was extubated.
Lipid emulsions in parenteral nutrition can interfere with pulmonary functions in patients displaying anomalies of the ventilation-perfusion ratio. The underlying mechanisms are unknown, but involve modifications of the production of vasoconstrictor and vasodilator eicosanoids as an effect of lipid infusion. Preferential synthesis of one or other of the eicosanoid types depends on the rate of administration of the lipids. Slow flow, corresponding to the administration of 100 g of triglycerides in 10-12 hours, leads to no change in the ventilation/perfusion ratio, and has no effect on gas exchange. TCM-based emulsions, which have little interference with eicosanoids, can be administered during ARDS. However, they have few benefits over a soy emulsion administered slowly. A new finding concerning lipid emulsions is the capacity of emulsions rich in long-chain polyunsaturated fatty acids of the n-3 series (DHA and EPA), derived from fish oil and of borage oil rich in gammalinoleic acid, to affect pulmonary inflammation and bronchial reactivity. These factors open up new and promising perspectives in the prevention and treatment of ARDS.
The extracellular matrix (ECM) does not simply maintain the form of tissues; it is a dynamic factor that plays a major role in cell function. Matrix metalloproteinases (MMPs) are the most important enzymes in ECM degradation, and their activity is controlled strictly by specific inhibitors, that is tissue inhibitors of metalloproteinase (TIMPs). We assessed the clinical course of changes in ECM-degrading enzymes TNF-α, IL-6, IL-8, and nitrite/nitrate (NOx) in the blood of two septic acute respiratory distress syndrome (ARDS) patients. Negative correlation was found between the PaO 2/FIO 2 ratio (P/F ratio) and MMP-1, but positive correlation was found between the P/F ratio and both the TIMP-1/MMP-1 ratio and MMP-1 • TIMP-1 complex level. TIMP-1 was consistently maintained at high levels. These results suggest that both MMP-1 and TIMP-1 may be involved in septic ARDS, and that the balance between MMP-1 and TIMP-1 is important.
Objective: To report the original observation of a patient with legionella's pneumopathy complicated with acute respiratory distress syndrome (ARDS) and a concomittant cerebral oedema occurred in the setting of positive end-expiratory pressure, reversible with the weaning of mechanical ventilation. Design and setting: Case report, Intensive Care Unit, General Hospital. Patient: Young female patient with HIV infection Interventions: Diagnostic fiberoptic bronchoscopy, legionella urinary antigen, lumbar puncture, computed tomography and magnetic resonance imaging of the brain, mechanical ventilation, positive end-expiratory pressure, low tidal volume, permissive hypercapnia, prone position, systemic antibiotherapy. Results: Cerebrospinal fluid polymerase chain reaction was negative for both legionella and herpes virus or any other opportunistic infection. Chest radiographies showed the progressive resolution of ARDS with adapted antibiotherapy. The clinical improvement and total reversibility of cerebral oedema were observed in magnetic resonance imaging of the brain with concomitant weaning of positive end-expiratory pressure and mechanical ventilation. Conclusion: In ARDS, protective ventilatory strategy using low tidal volume ventilation, positive end-expiratory pressure and permissive hypercapnia are recommended to improve intrapulmonary shunt, arterial oxygenation and to decrease mortality, but the incidence of neurological complications as intracranial hypertension is probably underestimated. Further studies to evaluate the neurological impact (hemodynamic and anatomical consequences) of mechanical ventilation in ARDS are necessary.
Objectives: To evaluate effects of permissive hypercapnia (PHC) on pulmonary mechanics and hemodynamics in patients with severe acute respiratory distress syndrome (ARDS). Methods: We observed the influence of different tidal volumes (V T) on pulmonary mechanics and hemodynamics in 10 patients with severe ARDS. Results: PHC was induced by decreasing V T from 10 - 12 ml/kg (routine V T) to 6 - 8 ml/kg (small V T). Arterial oxygen pressure and saturation remained unchanged, but pulmonary venous admixture was increased (p < 0.05). Airway plateau pressure and mean pressure were also decreased markedly. C 20/C, which reflects lung overdistention, was increased significantly. Mean arterial pressure, central venous pressure, pulmonary arterial wedge pressure and pulmonary arterial pressure were not changed, while systemic vascular resistance index was decreased markedly (p < 0.05). Cardiac index (CI) and oxygen delivery (DO 2) were increased (p < 0.05), while oxygen consumption remained unchanged. Conclusions: PHC, which was induced by small V T, might prevent lung overdistention and led to an increase in CI and DO 2.
Chronic myeloid leukemia (CML) is a hematologic malignancy characterized by clonal myeloproliferation of cells in the myeloid line, expressing the BCR-ABL fusion gene responsible for the oncogenic effect of the CML. Although the leukemic cells are minimally invasive, renal dysfunction is a known complication of the disease. Acute renal failure (ARF) caused by leukemic infiltration is relatively rare and often responds well to chemotherapy. We described an 80-year old CML patient who developed anuric ARF and was treated in our critical care nephrology (CCN) with hydrocarbamide in combination with impedance cardiography (ICG)-guided continuous venovenous hemodiafiltration (CVVHDF). Urine output was resumed and renal function improved within 1 day and 1 week, respectively. The chemotherapy and CVVHDF appeared to be effective therapeutic paradigm, whereas the use of ICG may offer extra guarantee especially in hemodynamically unstable patients. CCN could play a leading role in managing a broader spectrum of diseases rather than the adjunctive one of renal replacement therapy.
Acute renal failure is one of the most common organ failures occurring in critically ill patients. Mortality rates remain high despite treatment. This article will discuss the goals of prevention, pharmacologic and non-pharmacologic strategies including the role of diuretics and vasoactive agents, and will briefly consider future directions.
Background: We report the cases of 2 patients with severe pneumonia who exhibited increased changes in hypoxic pulmonary vasoconstriction (HPV) during temporary increases in stroke volume and decreased stroke volume variation caused by increasing positive end-expiratory pressure (PEEP) under different sedation.Cases: The first case was observed in a 79-year-old man with acute respiratory distress syndrome (ARDS) followed by pneumonia. The second case was observed in a 73-year-old woman on mechanical ventilation who suffered from ARDS following interstitial pneumonia.The first patient was treated with 2 kinds of sedatives to improve oxygenation and protect the lungs. The second patient was treated with 3 kinds of sedatives. The first patient had a low P/F ratio (53.9/0.7=77) on mechanical ventilation. According to the recruitment maneuvers, an increasing PEEP leads to a slight temporary increase in stroke volume of about 2 mL. The patient died 3 days later due to multiple organ failure and disseminated intravascular coagulation. The second patient had a low P/F ratio (38.5/0.7=55). As the PEEP increased, her stroke volume temporarily increased dramatically by about 8 mL. The patient recovered 56 days later.Conclusions: HPV is an obstacle to oxygenation, prompting recruitment maneuvers for treating mechanically ventilated ARDS patients; it is considered to be caused by physiological changes in the intracellular Ca2+ concentration in the pulmonary artery smooth muscle cells according to the sedation levels. The sedation level may contribute to decreased HPV in lung recruitment maneuvers.
We describe a patient with lobar atelectasis who was successfully treated with airway pressure release ventilation (APRV) after failed attempts at recruitment with endotracheal suctioning, chest therapy, and bronchoscopy. We review the literature on the effectiveness of the various methods to treat lobar atelectasis. Mechanically ventilated patients have an ineffective cough reflex and are unable to adequately deal with their respiratory sections. Atelectasis is therefore a common problem in these patients. The risk of atelectasis may be increased with the widespread use of a lung protective strategy utilizing low tidal volumes (6 ml/kg IBW). (1) Atelectasis may worsen hypoxemia through shunting and may predispose to nosocomial pneumonia. Traditionally the treatment of atelectasis in mechanically ventilated patients has centered on chest therapy (slapping, beating and vibrating) and endotracheal suctioning. (2) When this fails, bronchoscopy and/or recruitment maneuvers are attempted. (3) We describe the successful use of airway pressure release ventilation (APRV) for the treatment of atelectasis in a patient who failed the traditional treatment modalities.
The direct bilirubin/total bilirubin (D/T) ratio, which is not affected by such therapy as plasma exchange (PE), has been need for the determination of severity of acute hepatic failure. We studied 20 patients with acute hepatic failure who had received PE to examine whether the D/T ratio reflects prognosis, in association with tumor necrosis factor-alpha (TNF-α). Total bilirubin before the final PE was significantly higher than that before the initial PE (p=0.0064). No significant difference was observed between the D/T ratios before the initial PE and at the end of PE. No significant difference was observed between TNF-α before the initial PE and before the final PE. No significant correlation was observed among total bilirubin, D/T ratio, and TNF-α. No significant difference was observed between the survivor group and the nonsurvivor group in any factor. In the nonsurvivor group, total bilirubin before the final PE was significantly higher than that before the initial PE (p=0.0217). However, no significant difference was observed between the D/T ratios before the initial PE and before the final PE in the nonsurvivor group. In this study, the rise in total bilirubin reflected ineffectiveness of treatment. However, the D/T ratio failed to become an index of prognosis.
Objective: To look for predictors of mortality and rehospitalization, we conducted a prospective study using fifty variables from history, physical examination, ECG, CXR, Echocardiography and blood test (N Terminal proBNP, hsCRP, and lactate level) that suspected as predictors in heart failure Design: Blinded prospective cohort study Setting: Emergency room of Harapan Kita National Heart Center, Jakarta-Indonesia as entry site, with ICCU, wards, and OPD for evaluation. Patients population for study. All consecutive patients with acute decompensated heart failure class III-IV that were hospitalized. Exclusion criteria were other concomitant severe diseases. Measurements and result: Of 97 patients enrolled, variables were measured using standard protocols. During follow up period of six months, 11 (11.3%) patients died of cardiac origin and 29 (29.9%) rehospitalized. Logistic regression analysis revealed BMI >30 kg/m2 with edema had OR 6.6 (95% CI: 1.33-32.72, p=0,021), acute lung edema had OR 3,65 (CI 0,99-13,35, p=0,037), NYHA class IV had OR 5,42 (CI 95% : 1,11-26,59, p=0,037), left ventricle wall thickness >11 mm had OR 0,79 (CI 95 %: 0,63-1,00, p= 0,05), using beta-blocker had OR 0,09 (CI 95%: 0,01-0,74, p= 0,025), hemoglobin <12 g/dL had OR 4,53 (CI 95%: 1,24-16,56, p= 0,022), sodium <130 mmol/dL had OR 3,78( CI 95%: 1,02-14,03,p=0,047), NT proBNP >17,860 pg/mL on admission had OR 9,02 (CI 95 %: 2.30-35.30, p=0,02) or NT proBNP > 8,499 pg/dL at discharge had OR 13,2 (CI95%: 1,32-132,01, p=0,028) and served as predictors of mortality respectively. Using Cox Proportional Hazards and Kaplan Meier survival analysis and log rank test it were found that NT proBNP level >17.860 pg/ml on admission had a HR of 7.15 (95% CI 2.08-24.56, p=002) for mortality, while NT proBNP level >8.499 at discharged showed a HR of 9.55 (95% CI 1.06-85.77, p=0.044) for mortality. A decrease >35% of NT proBNP had a HR 0.13 (95%CI 0.02-1.19, p=0.071) for mortality, 0.38 (95% CI 0.14-1.00, p=0.049) for rehospitalization, and 0.42 (95%CI 0.12-0.76, p=0.010) for both. NT proBNP on admission >17.860 pg/dL together with EF <20 %, BMI >30 kg/m2 with edema and NYHA class IV were the most accurate predictor with AUC =0,94 (P=0.0001). Conclusion. Non decreased NT proBNP > 35 % during hospitalization was the predictor of mortality and rehospitalization. NT proBNP>17,860 pg/mL at entry, NT proBNP > 8,499 pg/mL at discharged, NYHA class IV, BMI>30 kg/m2 with edema, EF <20%, acute pulmonary edema, Rb <12 g/dL, Na <130 mmol/dL and not using beta-blocker were found as predictors for mortality of heart failure.
Background: The mechanisms underlying red blood cell fragmentation in intensive care patients remain controversial. Candida dubliniensis infection is very rarely reported in the world, and which has primarily been restricted to patients with a weakened immune system, and there is limited clinical information about the virulence of C. dubliniensis for hemolytic activity.Case: A 79-year-old man, who had recovered from acute respiratory distress syndrome (ARDS), presented with severe sepsis and was transferred to the emergency room. The ratio of arterial oxygen partial pressure to the fraction of inspired oxygenation (FiO2) (P/F ratio) in the arterial blood gas analysis was low (77%). Immediate treatment included intubation and antibiotic infusion. However, after 17 days, his general condition deteriorated suddenly, and red blood cell fragmentation was observed upon hematological examination. We treated him with an infusion of 4 units of packed red blood cells and 4000 units of haptoglobin. However, 3 days later, the patient died of multiple-organ failure and disseminated intravascular coagulation. Throughout the treatment period, C. dubliniensis pneumonia was detected twice in the examination of his sputum. Conclusion: To our knowledge, this is the first case report of red blood cell fragmentation in ARDS following C. dubliniensis pneumonia in Japan.
Cardiogenic shock is a cardiac emergency condition defined as the inability of the heart to supply sufficient blood in order to meet the needs of tissue basal metabolism, even though the intravascular volume is sufficient. This condition occurs mainly in acute myocardial infarction. The incidence of cardiogenic shock in acute myocardial infarction remains relatively unchanged over the last 23 years despite significant advances in the management of patients have been achieved. A dilemma on what the best strategy is in managing patients still persists: should it be conservative or aggressive? The criteria of cardiogenic shock according to SHOCK trial include clinical and hemodynamic parameters such as systolic blood pressures of < 90 mmHg for 30 minutes prior to inotropic or vasopressor administration; a condition where intraaortic balloon pump (IABP) is required to maintain the systolic blood pressure of ≥ 90 mmHg; evidence of decreased organ perfusion; and heart rate of ≥ 60 bpm. The hemodynamic criteria include a pulmonary capillary wedge pressure of ≥ 15 mmHg and an index cardiac output of ≤ 2.2/ min/ m2. Cardiogenic shock usually occurs as a result of left ventricular failure associated with acute myocardial infarction with only ≤ 40% of left ventricle mass involved in contraction. The main principle in the management of cardiogenic shock is to open the obstructed coronary vessels as soon as possible. It could be done either through thrombolysis or through invasive revascularization with percutaneous or surgical coronary intervention, popularly known as coronary artery bypass graft surgery (CABG). Various studies, both randomized and non-randomized, have supported more aggressive approach with early revascularization in the effort to increase patient life expectancy.
In an observational follow-up study from 1999 to 2000, we assessed respiratory sequelae in the youngest survivors of meningococcal septic shock (MSS) with acute hypoxic respiratory failure (AHRF). We included children who survived from MSS and AHRF, with a maximum age of five at follow-up. AHRF was defined based on the first, second and fourth criteria of the American-European Consensus Conference (A-ECC) on the acute respiratory distress syndrome (ARDS). Twelve children with AHRF were selected. Seven of these children had ARDS. Two children of those with ARDS suffered from respiratory sequelae. The degree of respiratory sequelae was associated with a lower ratio between the pressure of arterial oxygen and the fraction of inspired oxygen, with a higher oxygenation index, with a larger number of ventilation days and a higher lung injury score. Our observational results suggest that the incidence of long term respiratory sequelae in children after AHRF appears to be lower than previously reported, but may be higher in those who suffered ARDS. This observation requires further confirmation in future studies within homogeneous and well defined study populations.
Background: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are major causes of morbidity and mortality in pediatric intensive care units (PICUs). Prior work has shown disorder of inflammation and coagulation in ALI/ARDS. Activated protein C (APC) is a potential critical endogenous regulator of coagulation and inflammation in ALI/ ARDS. Material and Methods: We prospectively studied children admitted with ALI/ARDS. We obtained clinical data, initial blood coagulation profiles including plasma protein C (PC) activity and free protein S antigen (PS Ag). Results: 27 patients with ALI/ARDS were recruited in our study; their mean age was at 6.4±5.2 years. Fifteen were survivors (55%), 12 were non-survivors (45%). Initial plasma PC activity was 72.0±27.6% and plasma free PS Ag was 58.52±29.8%. Platelets, PT & PTT were significantly abnormal compared between survivors and non-survivors (p=0.01, 0.02, 0.01). There was a significantly negative correlation between plasma PC with initial systolic blood pressure (r=0.5, p=0.008) and PS Ag (r=0.41, p=0.02). There was also a trend of negative correlation between plasma PC with ventilator day (r2=0.0009, p=0.1) and length of stay in PICU (r2=0.1, p=0.09). Conclusions: This study suggests that most of our pediatric ALI/ARDS had abnormal coagulogram. Coagulation dysfunction including initial plasma PC activity might be associated with the overall outcome.
Systemic lupus erythematosus is an autoimmune disease that usually develops neurological manifestations in a high percentage of the cases. Acute transverse myelitis is a rare neurological complication with significant possibility of damage, sequelae and poor prognosis. We present the case of a patient with systemic lupus erythematosus and acute transverse myelitis who responded adequately to treatment with intravenous steroids and cyclophosphamide. Having in mind acute transverse myelitis as a possibility in any patient with systemic lupus erythematosus, allows us to be ready and able to diagnose and treat this complication early, avoiding sequels and poor prognosis.
Many patients are admitted to intensive care unit for acute intoxication, serious complication of overdose or withdrawal symptoms of illicit drugs. Acute withdrawal of drug with addiction potential is associated with sympathetic over-activity leading to marked psychomimetic disturbances. Acute intoxication or withdrawal of such drugs are often associated with life threatening complication which requires ICU admission and necessitates prolonged sedative-analgesic medications, whereas weaning from which is often complicated by withdrawal and other psychomimetic symptoms. Dexmedetomidine, an α2 agonist has been used successfully to facilitate withdrawal and detoxification of various drugs and also to control delirium in ICU patients. Herein we reported two cases of chronic substance abuse patients admitted with acute overdose complication leading to prolonged ICU course requiring sedative-analgesic, and later the drug withdrawal related symptoms further complicated the weaning process. Dexmedetomidine infusion was successfully used as sedative-analgesic to control the withdrawal related psychomimetic symptoms and to facilitate smooth detoxification and weaning from opioid and other sedatives.
Objective: To assess the effectiveness of intravenous (IV) thiamine in reducing hyperlactatemia in septic shock patients. Design: Prospective, randomized controlled trial. Setting: General intensive care unit (GICU), Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur. Patients and participants: Adult patients with septic shock and hyperlactatemia (lactate ≥2 mmol/l). Interventions: IV thiamine 200 mg thrice daily for 3 days. Measurements and results: A total of 72 patients were recruited into the study. Seven patients died within 24 hours of study commencement and were dropped out. Patients were randomized into the thiamine group (TG) who received IV thiamine 200 mg diluted in 50 ml of normal saline, or placebo group (PG) who received 50 ml of normal saline infusion over 30 minutes. Arterial blood lactate samples were collected at time of enrolment, after 6, 12, 18, 24, 48, and 72 . hours of study drugs administration. Relative lactate changes over 24 hours, duration of weaning off vasopressors, Sequential Organ Failure Assessment (SOFA) score changes over 72 hours, ICU length of stay (LOS) and mortality rates were compared between groups. There were no significant differences in the relative lactate changes (TG: 37.5% [4.7-59.1] vs PG: 47.8% [29.1-70.7], p=0.091), duration of vasopressors being weaned off (TG: 75.5 [48.0-131.25] vs PG: 88.0 [48.0-147.0]), SOFA score changes (TG: 3.0±3.41 vs PG: 2.7±3.3), ICU LOS (TG: 5.0 [4.0-11.0] vs PG: 6.0 [3.0-12.0]), and ICU mortality rate (TG: 14 [43] vs PG: 12 [37]). Multivariate logistic regression test showed that baseline lactate level was an independent predictor for mortality (p=0.044). Conclusion: Intravenous thiamine did not show significant improvement in relative lactate changes, time for shock reversal, SOFA scoring, ICU LOS, and mortality rate in septic shock patients with hyperlactatemia. However, baseline lactate level was shown to be an independent predictor for ICU mortality. © 2019, The Indonesian Foundation of Critical Care Medicine. All rights reserved.
Background: Water irrigation during transurethral resection of prostate (TURP) often caused hyponatremia, hypoosmolality, and decreasing of pH called TURP syndrome. Current standard fluid therapy in TURP still could not prevent or correct TURP syndrome. This study was aimed to assess the efficacy and safety of preoperative hypertonic sodium lactate (HSL) infusion in maintaining plasma sodium level, osmolality, arterial pH and hemodynamic parameters during TURP compared to normal saline (NS). Methods: In this prospective randomized controlled double blind study, 22 patients underwent TURP surgery under spinal anesthesia were assigned into 2 groups with 11 patients in each group. HSL or NS were administered before spinal anesthesia with loading dose 4 mL.kgBW-1 within 20 minutes. During procedure NS with 2-4 were infused as maintenance in both groups. Result: Postoperative mean of sodium level and osmolality in HSL group was significantly different compared to NS group (142.2±2.0 mEq/L vs 138.9±2.1 mEq/L, p<0.05, and 294.6±3.5 mOsm/kg vs 290.6±3.2 mOsm/kg, p<0.05) respectively. Postoperative pH in HSL group was 7.433±0.04, whereas in NS group was 7.356±0.05 (p<0.05). Evolution of hemodynamic parameters was better in HSL group. Five of 11 patients in NS group need ephedrine injection due to decreased of blood pressure >30% after spinal anesthesia, whereas none of patients in HSL group need ephedrine. Conclusion: Preoperative administration of hypertonic sodium lactate in TURP was better in maintaining plasma sodium level, osmolality, arterial pH and also hemodynamic parameters than normal saline.
Background: The mortality rate of critically-ill children with multiple organ dysfunction syndrome (MODS) in Indonesia is approximately 51.85%. Various studies suggested malnutrition as a risk factor for mortality; therefore, nutrition therapy in the form of initial caloric administration became imperative. Objective: To determine the relationship between initial caloric administration (initial route, initial time and the fulfilment of caloric requirement) and mortality of critically-ill children. Design: Case-control study. Setting: The Pediatric Intensive Care Unit (PICU) of Dr. Sardjito General Hospital Yogyakarta in 2015. Patients and participants: Children aged 1 month to 18 years old hospitalized in the PICU for at least 4 days in 2015. Subjects were divided into case group (non-surviving patients) and control group (surviving patients). Measurements and results: We used McNemar test and stepwise conditional logistic regression for data analysis. From 102 subjects (51 in each group), the proportion of malnourished children in the case group was higher than in the control group (58.8% and 29.4%, respectively). Parenteral route and lack of caloric achievement within the 3rd to 6th day of hospitalization significantly increased the risk of mortality (p<0.05) with ORs of 13 (95%CI 1.95 to 552.47), 3.8 (95%CI 1.37 to 13.02), 4.25 (95%CI 1.39 to 17.26), 4.00 (95%CI 1.08 to 22.09), and 10.0 (95%CI 1.42 to 433.98), respectively. Caloric initiation after the first 48 hours of hospitalization did not significantly affect the mortality rate (p>0.05). Confounding variables that affected mortality include the severity of disease, use of ventilator, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and malnutrition (p<y0.05). Multivariate analysis revealed that parenteral route and malnutrition significantly influenced mortality with ORs of 36.05 (95%CI 3.22 to 404.13) and 9.04 (95%CI 2.09 to 39.19), respectively. Conclusion: There is a relationship between route of initial caloric administration and mortality of critically ill children, where parenteral nutrition significantly influenced mortality in critically ill children. © 2018, Indonesian Society of Critical Care Medicine. All rights reserved.
Objective: To describe the administration of vincristine and daunorubicin to a 14-year-old girl requiring ECMO support due to a non-Hodgkin's lymphoma mediastinal mass. Design and Setting: Patient case report in an 18-bed level 1 medical-surgical Pediatric Intensive Care Unit (PICU) in a free standing children hospital. Patients: A 14-year-old adolescent female admitted to the PICU. Each author's Institutional Review Board deemed this project exempt. Results: A 14-year-old previously healthy adolescent girl presented with a 3 month history of progressively worsening respiratory diffi culties. A large mediastinal mass and pleural effusion were found on computerized tomography (CT) scan. Soon after, the patient had multiple cardiac arrests and resuscitations and was deployed on ECMO. The treatment protocol for her lymphoma included high dose methylprednisolone, vincristine, and daunorubicin. The administration of all medications for this patient, including her chemotherapeutic agents, was done during concurrent use of ECMO and hemofi ltration dialysis. Conclusion: Administration of vincristine during ECMO has rarely been described, and this is the fi rst description of use of daunorubicin with ECMO. Since daunorubicin has a rapid and extensive distribution into tissues, a large volume of distribution, modest protein binding, and mainly hepatic metabolism, dosing adjustment was not necessary during ECMO. Vincristine is also rapidly and extensively distributed throughout the body, has a large volume of distribution, and undergoes hepatic metabolism. However, because of its relatively large protein binding and potential for binding in the membrane oxygenator, the vincristine dose was increased by 25% over the standard protocol. There is little published information regarding dosing of medications during ECMO, especially daunorubicin and vincristine, and even less during ECMO with concurrent hemofi ltration dialysis. Additional studies are needed to optimize medication dosing during ECMO.
Top-cited authors
Margaret M Parker
  • Stony Brook University
Richard dellinger
  • Cooper University Hospital
Jean-Louis Vincent
  • Université Libre de Bruxelles
Juan C Gea-Banacloche
  • Mayo Foundation for Medical Education and Research
Joseph Varon
  • University of Texas Health Science Center at Houston