Internal jugular vein thrombosis and central venous catheter

Authors: Ricardo de Jesús Avendaño-Garnica, Santiago Herrero, Joseph Varon

A sixty-seven-year-old gentleman, with atherosclerotic cardiovascular disease, stable angina, and hypertension was admitted to the hospital with several episodes of chest pain. An electrocardiogram revealed ST-T changes in the anterior wall. A coronary angiography followed by an angioplasty resulted in placement of 2 stents for critical lesions on the left anterior descendent artery. Within minutes, the patient became hypotensive with signs of hypoperfusion. Bedside echocardiography revealed cardiac tamponade. An emergency pericardial drainage was placed, and the patient taken to the cardiac catheterization laboratory where a repeat angiogram revealed a right coronary artery perforation as well as a small distal branch of the posterior descendent artery.

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The primary, secondary, and tertiary brain injury

Authors: Eko Prasetyo

Abstract

Traumatic brain injury (TBI) is one of the most prevalent causes of morbidity and mortality all over the world. The knowledge and understanding of pathophysiology of TBI are the priority as a basic to develop therapeutic opportunities and allow improvement of outcome for TBI patients. In TBI, primary damage occurs at the time of impact and the damage is preventable but not treatable. The process will continue caused following trauma due to complicating processes. Secondary brain insults have been found in many patients of severe TBI. This insult continues, which involves complex molecular and genes cascades, and is not fully understood. Chronic microglia activation and epigenetic mechanism were potential entry point in third brain damage processes. We suggest that treatment of tertiary insults might be ameliorate chronic complication of severe TBI patients.

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Advances of hemodynamic monitoring and the current state of fluid resuscitation in clinical practice

Authors: Antonius Hocky Pudjiadi

Abstract

Fluid resuscitation remains the most common and the most debated intervention for critically ill patients. Fluid resuscitation is recommended as a principal therapy in various critical care guidelines, despite the low quality of evidence backing its safety. Fluid overload may lead to a lot of adverse effects, necessitating a reliable method to predict the patient’s hemodynamic response to fluid resuscitation. This review summarizes various hemodynamic monitoring techniques developed over the years and their role in guiding fluid resuscitation, such as the Swan-Ganz catheter, transpulmonary thermodilution, Doppler ultrasound, and impedance cardiography. Each of these techniques comes with differing advantages and shortcomings, as well the appropriate clinical settings in which these techniques can be applied. Existing protocols, which recommend fluid resuscitation as well as evidences pointing against its clinical safety are also discussed.

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Early hydrocortisone, ascorbate and thiamine therapy for severe septic shock

Authors: Micah T. Long, Mark A. Frommelt, Michael P. Ries, Melissa Murray, Fauzia Osman, Bryan M. Krause, Pierre Kory

Abstract

Objective: Septic shock is a devastating physiological state with significant mortality risk. Recently, trials have suggested clinical benefits of adjunctive treatment with iHAT. These agents may reduce oxidative stress, inflammation, mitochondrial dysfunction and endothelial injury in patients with septic shock. The primary objective of this study was to evaluate intensive care unit (ICU) and hospital mortality for patients with septic shock treated with and without intravenous hydrocortisone, ascorbic acid and thiamine (iHAT).

Design: A retrospective cohort study was performed evaluating patients admitted with septic shock requiring vasopressors to the ICU treated with and without iHAT.

Setting: The intensive care unit of a tertiary care academic center in Madison, WI

Patients: Of 3,463 patients admitted to the ICU, 206 met inclusion criteria with 127 treated according to standard care (SC) and 79 receiving additional adjunctive iHAT.

Intervention: Hydrocortisone 50 mg IV q6h, Ascorbic Acid 1500 mg IV q6h and Thiamine 200 mg IV q12h.

Measurements and results: Acute Physiology And Chronic Health Evaluation (APACHE) scores were higher in the SC cohort. Observed ICU mortality was lower in the iHAT cohort compared to SC as was APACHE-adjusted ICU mortality (OR 0.44, p=0.043). APACHE-adjusted ICU mortality was lowest when iHAT was initiated within 6 hours (OR 0.08, p<0.01). Hospital mortality, vasopressor duration, initiation of renal replacement therapy and lengths of stay were not significantly different between cohorts.

Conclusion: There was a time-sensitive improvement in APACHE-adjusted ICU mortality in septic shock patients treated with adjunctive iHAT. The strong temporal benefit of iHAT therapy has important implications towards future studies.

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Correlation between middle cerebral artery pulsatility index and optic nerve sheath diameter with intracranial pressure in traumatic and non-traumatic brain injury patients of Dr. Soetomo General Hospital Surabaya

Authors: Hamzah, Arie Utariani, Bambang Pudjo Semedi, Yoppie Prim Avidar, Nanang Nurofik

Abstract

Background: Patients with brain injury experience pathology of increased intracranial pressure (ICP), which is the cause of secondary brain injury, brain herniation at the risk of brain damage. Intracranial pressure control and monitoring is one of the most important strategies in managing patients in the neurosurgery and neurointensive care fields. Intracranial pressure monitoring in Dr. Soetomo General Hospital Surabaya is still limited by intraventricular catheter installation, which is invasive. The middle cerebral artery pulsatility index (PI) and sonographic optic nerve sheath diameter enable non-invasive monitoring of intracranial pressure. This study aimed to find out the correlation between middle cerebral artery pulsatility index and optic nerve sheath diameter with intracranial pressure.

Methods: Transcranial doppler measurement was made transtemporally to measure middle cerebral artery pulsatility index. Optic nerve sheath diameter was measured 3 mm behind the globe using 12 MHz US probe. Intracranial pressure was measured using intraventricular catheter. The correlation and regression between intracranial pressure, pulsatility index, and optic nerve sheath diameter were investigated.

Results: Thirty patients with various intracranial pathology, who underwent intraventricular catheter placement, were included in the study. A total of 86 intracranial pressure examinations, middle cerebral artery pulsatility index, and optic nerve sheath diameter were conducted. A significant correlation was found between pulsatility index and intracranial pressure with a correlation coefficient of 0.639; intracranial pressure = 9.23 x PI + 4 mmHg. Pulsatility index sensitivity was 93.2% with specificity 75.0%. Cut-off point was >1.11 for pulsatility index to detect increased intracranial pressure. The optic nerve sheath diameter and intracranial pressure correlation coefficient is 0.746; intracranial pressure = 7.88 x optic nerve sheath diameter - 26.84 mmHg with sensitivity 92.3% and specificity 95.83%. Optic nerve sheath diameter cut-off value was 5.4 mm.

Conclusion: There was a correlation between middle cerebral artery pulsatility index and optic nerve sheath diameter with intracranial pressure. Pulsatility index and optic nerve sheath diameter can be used as alternative for ICP monitoring.

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Role of S100B, sTNFR-1, lactate, ScvO2, and SctO2 measured by NIRS as predictor of neurological deficit in pediatric congenital heart surgery

Authors: M. Tatang Puspanjono, Sri Rezeki SH Hadinegoro, Bambang Sutrisna, Suhendro, Tjipta Bahtera, Amir S. Madjid, Siti Boedina Kresno, Dwi Putro Widodo, Rubiana Sukardi

Abstract

Background: Process related to systemic inflammatory response syndrome (SIRS) in congenital heart disease (CHD) surgery using cardiopulmonary bypass (CPB) machine often causes post-operative complications. This process begins with mitochondrial dysfunction in SIRS, initiated by the release of inflammatory mediators such as tumor necrosis factor receptor-α (TNF-α) and soluble tumor necrosis factor receptor-1 (sTNFR-1). Neurological injury following pediatric congenital heart surgery remains common. Studies related to brain-derived protein (S100B) biomarker for cerebral hypoxia caused by microcirculation and mitochondrial dysfunction as a consequence of SIRS in CPB or pediatric CHD surgery have yet to be conducted. Observation to identify cerebral hypoxia is necessary due to the fact that early stages of cerebral hypoxia are often asymptomatic. Near-infrared spectroscopy (NIRS) is a tool used for observing oxygen delivery to the brain by measuring cerebral oxygen saturation (SctO2). In Indonesia, NIRS remains uncommon and no study has been conducted to date.

Objectives: To evaluate the role of S100B, sTNFR-1, lactate, and superior vena cava and cerebral saturations as predictors of neurological injury in CHD patients undergoing corrective surgeries, as measured using NIRS during and after surgical procedure.

Methods: This was a prospective cohort study. Inclusion criteria were pediatric patients with CHD aged 1 month to 6 years old undergoing corrective surgery. Exclusion criteria were patients with Down syndrome, single coronary artery, and not consented to participate in the study. For analysis, subjects were divided into 2 groups: (1) those with neurological deficits and (2) those without neurological deficits. All subjects were observed closely in intensive care unit (ICU) until they were discharged. Blood examinations were performed 3 times: before surgery, after CPB, and 4 hours after CPB.

Results: Fifty-one patients were observed from March to October 2015. Significant differences were observed in the value of S100B, STNFR-1, lactate, and area under the curve (20% AUC) baseline for cerebral saturation between both groups, as measured using NIRS. Those parameters could be used as predictors of post-CPB neurological deficit incidence in children with CHD.

Summary: In CHD patients undergoing corrective surgery, S100B value, sTNFR-1, lactate, and 20% AUC baseline for cerebral saturation could be used as predictors of neurological deficit following corrective surgery.

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Multiple ventricular septal defects in an adult

Authors: Kashmala Khan, Carlos Vargas, Salim R. Surani

Ventricular septal defect (VSD) is the second most commonly occurring congenital heart defect in adults. The incidence in adults is 10 %, as most defects usually close during early childhood. Mortality increases with age, and 75% at the age of 60. Symptoms and clinical presentation depend mainly on the size of the VSD. Patients with small VSDs usually remain asymptomatic. Larger VSDs can cause hemodynamic compromise, increased risk of infective endocarditis and reversal of shunt leading to Eisenmenger syndrome.

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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.

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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.

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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.

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