Subarachnoid pneumorrhachis following blunt thoracic and spinal trauma

Authors: Ravi Mistry, Sarah Wongseelashote, Ross Freebairn

Abstract

Subarachnoid pneumorrhachis is an increasingly identified entity in the setting of trauma. We report a case of this finding incidentally and of a positive outcome with conservative management following multi-speciality opinion. Our case-series review identifies an increasing number of cases in the literature due to improvements in computerised tomography resolution and explores traumatic and non-traumatic precipitants, suspected mechanisms of introduction of air into the spinal canal and ventricular systems and support for non-interventional management in uncomplicated pneumorrhachis.

Read More

Blood lactate levels during cardiopulmonary bypass as indicator of outcome in pediatric cardiac surgery

Authors: M. Tatang Puspanjono, Antonius H. Pudjiadi, Jusuf Rachmat, S. Harry Purwanto

Abstract

Objectives: In pediatric cardiac surgery, high blood lactate levels during cardiopulmonary bypass (CPB) are associated with tissue hypoperfusion and contribute to postoperative complications. Studies indicate that blood lactate level is proportional to tissue oxygen debt. The objective of this study was to evaluate the change in blood lactate levels and perioperative morbidity and mortality.

Methods: We conducted a retrospective analysis of 81 pediatric patients who have undergone cardiac surgery with continuous monitoring of serial measurement of blood lactate in Integrated Cardiac Service Unit, Dr. Cipto Mangunkusumo Hospital, Jakarta. Arterial blood samples were taken before, during CPB, and on admission to the Intensive Care Unit (ICU) and every 6 hours afterward. Duration of CPB, hemodynamic parameters, inotrope dosage and perioperative outcome were documented.

Results: The largest increment in lactate level occurred during CPB and decreased on admission to the ICU. Patients who had complications exhibited higher lactate levels at all time points. Lactate levels were higher in the group with complications at the end of surgery (4.4 vs 2.7 mmol/l; p=0.000), immediately after ICU admission (2.9 vs 1.9 mmol/l; p=0.000), 6 hours (1.9 vs 1.4 mmol/l; p<0.003), and 12 hours after admission (4.6 vs 2.8 mmol/l; p=0.000). Increased lactate concentration was reliably associated with patient length of ICU stay, liver function parameter and anion gap. Logistic regression analysis revealed that peak blood lactate levels of 3.5 mmol/l or higher during CPB were strongly associated with postoperative mortality and morbidity.

Conclusions: Hyperlactatemia occurs during CPB may become an early indicator/predictive index for postoperative morbidity and mortality in pediatric patients. This study generates the hypothesis that strategies aimed to preserve oxygen delivery during CPB may reduce the occurrence of elevated lactate levels.

Read More

Serum glial fibrillary acidic protein is a more specific biomarker than phosphorylated neurofilament heavy subunit, heart-fatty acidic protein, neuron specific enolase, and S100B protein for CT-positive mild-to-moderate traumatic brain injury

Authors: Tadashi Kaneko, Tadashi Era, Kohei Karino, Shu Yamada, Maki Kitada, Toshihiro Sakurai, Masahiro Harada, Fumihiko Kimura, Takeshi Takahashi, Shunji Kasaoka

Abstract

Background: Several biomarkers show diagnostic value for traumatic brain injury (TBI), especially in patients with severe TBI. In the present study, we examined whether glial fibrillary acidic protein (GFAP), phosphorylated neurofilament heavy subunit (pNF-H), heart-type fatty acid binding protein (H-FABP), neuron-specific enolase (NSE), and S100B protein (S100B) measured on admission to an emergency department showed diagnostic value in patients with mild-to-moderate TBI.

Methods: A prospective study performed in our emergency department. After collecting informed consent, blood samples were obtained to measure GFAP, pNF-H, H-FABP, NSE, and S100B concentrations. All of the patients underwent head computed tomography (CT). The CT findings were considered positive if hemorrhagic brain injury was present. Receiver-operating characteristic (ROC) curve analysis was performed for each biomarker with positive head CT findings as the outcome variable.

Results: Fifty-seven patients were included (39% male). Their median age was 70 years and the median Glasgow coma scale score was 15. Twelve patients (21%) had positive head CT findings (CT-positive group). The area under the ROC curves for GFAP, pNF-H, H-FABP, NSE, and S100B were 0.845, 0.569, 0.518, 0.744, and 0.753, respectively, and were statistically significant for GFAP, NSE, and S100B (p<0.001, p=0.013, and p=0.010, respectively). The area under the ROC curve was greater for GFAP than those for the other biomarkers.

Conclusions: Our results suggest that serum GFAP measured shortly after emergency department admission shows greater diagnostic potential for head CT-positive TBI as compared with pNF-H, H-FABP, NSE, and S100B.

Read More

Effects of N-acetylcysteine on high-sensitive C-reactive protein level and wall motion score index after ST-segment elevation myocardial infarction and fibrinolytic therapy: A randomized trial

Authors: Trisulo Wasyanto, Savithri Indriani, Ahmad Yasa

Abstract

Objective: To determine the effect of N-acetylcysteine (NAC) on the high-sensitive C-reactive protein (hsCRP) level and wall motion score index (WMSI) in patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy.

Methodology: We performed a randomized pre-post study in consecutive patients who received fibrinolytic therapy for STEMI at Dr. Moewardi Hospital from July through August 2018. Patients were randomly allocated to receive NAC 600 mg 3 times daily for 3 days (treatment group) or no NAC (control group). Patients underwent pre- and post-treatment hsCRP measurement and echocardiographic examination with calculation of the WMSI. Pre- and post-therapy differences in clinical characteristics were analyzed within and between groups using independent sample t-, Mann-Whitney, paired t-, and Wilcoxon tests as appropriate.

Results: Thirty-two patients were analyzed. The control and treatment groups included 15 (mean age 58.27±8.07 years) and 17 (mean age 55.24±10.19 years) patients, respectively. There were significant between-group differences in hsCRP levels (p=0.001) and WMSIs (p=0.005) after therapy. In the control group, the median post-therapy hsCRP and WMSI were 151.50 mg/l (range 42.50-285.20) and 1.3 (range 1.1-1.7), respectively, compared to 14.90 mg/l (range 3.60-266.80) and 1.2 (range 1.0-1.5), respectively, in the treatment group.

Conclusion: Patients with STEMI who received NAC (600 mg 3 times daily for 3 days) in addition to fibrinolytic therapy had lower post-intervention hsCRP levels and WMSIs than patients who received fibrinolytic therapy alone. These findings will provide a therapeutic option for the successful management of patients with AMI.

Read More

Intravenous thiamine as an adjuvant therapy for hyperlactatemia in septic shock patients

Authors: Nur Fazlina Harun, Saw Kian Cheah, Aliza Mohamad Yusof, Chee Lan Lau, Azlina Masdar, Siti Nidzwani Mohamad Mahdi, Nurlia Yahya, Norma Mohamad, Raha Abdul Rahman

Abstract

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.

Read More

Sigmoid volvulus: An image telling the story

Authors: Gerardo Rivera, Salim Surani, Joseph Varon

A 77-year-old gentleman, with past medical history of dementia and psychosis, presented to the emergency department with a chief complaint of abdominal distention. X-ray imaging of the abdomen revealed air filled distended loops of large bowel (Figures 1A and 1B). Computerized tomography (CT) revealed marked dilatation of the large intestine, from the cecum to the sigmoid colon where there is a beak-shaped transition as well as multiple air fluid levels without free air (Figures 2a and 2b). A bedside colonoscopic decompression was performed with resolution of the volvulus.

Read More

Comparison of outcome between percutaneous dilatation tracheostomy and surgical tracheostomy in Intensive Care Unit of Dr. Wahidin Sudirohusodo Hospital Makassar

Authors: Syafri K. Arif, Andy Setiawan, Hisbullah, Faisal Muchtar, Haizah Nurdin

Abstract

Percutaneous dilatation tracheostomy (PDT) has been widely used in Indonesia, yet no study to evaluate the outcome of PDT compared to surgical tracheostomy (ST) is available.

Objective: This study was aimed to evaluate the use of PDT in Indonesia.

Design: Non-randomized comparative retrospective study.

Setting: Intensive Care Unit of Wahidin Sudirohusodo Hospital Makassar.

Patients: Eighty-four patients aged 15 to 90 years, undergone tracheostomy during 2016 to 2017 were evaluated.

Measurements and results: Samples were evaluated in terms of surgical duration, blood loss volume, mortality, and complication rates such as post-operative bleeding, pneumothorax, subcutaneous emphysema, stomal infection, tracheal stenosis/malacia, and unintended fistula formation. Collected data were analyzed with SPSS version 22. Mean operative duration of PDT (18.3 minutes) were significantly faster than ST (40.2 minutes) (p<0.05), accompanied by significant reduction of mean blood loss 13.6 ml compared to 21.1 ml in ST group (p<0.05). A total of 9 complications (18.8%) found in ST group and 5 (13.9%) in PDT group, with stomal infection was the most common complications. Mortality rate were 52.8% in PDT group and 45.8% in ST group (p>0.05), none associated with the procedure itself.

Conclusion: It is suggested that PDT is a superior technique in placement of tracheostomy canula.

Read More

Case report: a fatal case of severe pancreatitis associated with rhabdomyolysis

Authors: Saw Kian Cheah, Mohamed Izzad bin Isahak, Wan Rahiza Wan Mat, Shereen Suet Ping Tang, Rufinah Teo, Aliza Mohamad Yusof, Raha Abdul Rahman

Abstract

Background: Rhabdomyolysis is an uncommon presentation associated with severe acute pancreatitis (SAP). Patients usually present late and asymptomatic, thus it carries poorer clinical outcome and higher mortality rate.

Case report: We report a case of SAP in a 42-year-old man who presented with persistent epigastric pain, elevated serum amylase, and characteristics of acute pancreatitis on the contrast-enhanced computed tomography of the abdomen. Investigations revealed persistent hyperkalemia and severely elevated creatinine kinase in the presence of acute kidney injury, which led to the uncommon possibility of diagnosing severe rhabdomyolysis. He suffered complications of intra-abdominal hypertension, feeding intolerance, severe ARDS and multi-organ failure. He succumbed to death after a month despite aggressive intensive care therapies and support.

Discussion: The actual pathophysiology of rhabdomyolysis in SAP is complex. It is postulated that acute inflammation of pancreas causes ATP-dependent proton pump dysfunctions leading to skeletal muscle cells injury and therefore, rhabdomyolysis.

Conclusion: Coexistence of rhabdomyolysis with SAP have higher risk for fatality, therefore, its presence allows early triage, early aggressive resuscitation and intensive care management.

Read More

When you know too much for your own good: The Boston-Varon syndrome

Authors: Joseph Varon, James Boston

It has been stated that knowledge is everything. However, sometimes this can actually be counterproductive. For example, the so-called “medical students' disease” (or second-year syndrome, intern's syndrome), has been described as a condition in medical students, who perceive themselves to be experiencing the symptoms of a disease that they are studying. This syndrome is associated with an intense fear of contracting the disease in question.

An identical syndrome could potentially be ascribed to those who care for patients, and in whom on of their family members suffer a condition that requires diagnosis. Here, we describe a variant of such syndrome, for which we have coined the term Boston-Varon Syndrome (BVS).

Read More

McConnell’s sign is not specific for acute pulmonary embolism – A case report

Authors: Mohamad Iqhbal Bin Kunji Mohamad, Mohd Fazrul Bin Moktar, Julina @Azimah Mohd Noor, Nur Abdul Karim, Izzat Bin Ismail, Abdul Halim Bin Sanib, Mohd Amin Mohd Mokhtar, Safreeda SF Salim

Abstract

Since 1996, McConnell’s sign, defined as right free wall hypokinesia with apical sparing, described as one of the most specific echocardiographic finding for acute pulmonary embolism. It was incorporated in the standard teaching and text book as a tell-tale sign for the condition. This is a case report of a patient presented with chest pain and presyncope with markedly raised D-dimer and suspicious electrocardiogram finding. The bedside focused cardiac ultrasound revealed the classical McConnell’s sign. However, the computed tomography pulmonary angiogram for pulmonary embolism was negative. The patient was subsequently diagnosed as pulmonary hypertension secondary from chronic methamphetamine abuse. This case highlights that McConnell’s sign is not specific for acute pulmonary embolism. It is also important to stratify patient according to a validated clinical probability score for pulmonary embolism before initiating definitive acute treatment.

Read More