Ureteral stents, sepsis and acute kidney injury: Iatrogenic imperfecta!

Case presentation

A 62-year-old woman with a past history of placement of bilateral ureteral “JJ” stents, presented to the hospital complaining of fever, chills, abdominal pain, oliguria and was found to be hypotensive. She was admitted to the intensive care unit (ICU), with the diagnosis of sepsis secondary to a urinary source. Her white blood cell count (WBC) was 21,200/mm3, blood urea nitrogen (BUN) 40 mg/dL, and serum creatinine 2.1 mg/dL. Her systolic blood pressure was 75 mmHg after administration of bolus of intravenous fluid (30 ml/Kg). She was then started on norepinephrine with improvement in her mean arterial blood pressure.


Mediastinal lipoma with vascular compression

Case description

A 56-year-old gentleman presented to the emergency department with shortness of breath and neck swelling of a couple of weeks duration. After a comprehensive physical examination and chest radiograph revealing an upper mediastinal abnormality, a computed tomography (CT) scan of the chest (Figures 1A and 1B) depicted a 8x7x5.7 cm mass with homogenous fat density and smooth margin, that was causing compression and anterior displacement of the superior vena cava and the left brachiocephalic vein. The patient underwent urgent surgery with removal of the tumor and postoperatively his symptoms had subsided.


Characteristics of the obstetric patients admitted to the Intensive Care Unit of Sanglah General Hospital in 2013-2016

Abstract

Background: High risk pregnancy and complication during pregnancy or labor may need multidisciplinary management in the Intensive Care Unit (ICU). This study shows the characteristics of obstetric patients who were admitted to the ICU of Sanglah General Hospital Denpasar, Bali, Indonesia in 2013 to 2016.

Objective: Our study was performed to provide database in Sanglah General Hospital regarding to the intensive care management of obstetric patients in the ICU of Sanglah General Hospital. This data may be beneficial to provide better management in the ICU, and also to reduce maternal mortality and morbidity.

Design: This was a descriptive study using the secondary data from the medical records of obstetric patients who were admitted to the ICU of Sanglah General Hospital in 2013 to 2016.

Setting: This study was performed in the ICU of Sanglah General Hospital, Denpasar, Bali, Indonesia.

Patients and participants: All obstetric patients who were admitted or transferred to ICU of Sanglah General Hospital in August 1, 2013 to August 31, 2016. There were 245 obstetric patients transferred to ICU of Sanglah General Hospital.

Result: Over the 3 years study period, there were 245 obstetric patients who were admitted to the ICU out of the total of 3089 deliveries during that period. Based on the gestational age during admission, there were 7.7% cases below 28 weeks (n=19), 36.3% were between 28-36 weeks gestational age (n=89), and 55.9% cases were 37 weeks and above (n=137). The indication of the admission can be categorized into the obstetrics indication, which were 75.1% out of 245 cases (n=184) and the non-obstetric indication such as the medical problem underlying during the pregnancy, which were about 24.9% out of 245 cases (n=61). The major indication of obstetric problem was the hypertensive disease in pregnancy, while the major indication of nonobstetric reason was the heart disease. The maternal mortality rate in the ICU during this study was 10.2% out of the 245 cases who were admitted to the ICU.

Conclusion: As the major tertiary referral hospital in Bali, Sanglah General Hospital were having high number of complicated pregnancy cases. The characteristics of the obstetric patients who were admitted to the ICU can be used to plan better management and appropriate care, especially in the ICU, in order to reduce the maternal mortality rate.


Prevalence and association of cost and hospital malnutrition in Pediatric Intensive Care Unit Sanglah Hospital during 2015

Abstract

Background: Early nutritional screening and adequate enteral nutrition for critically ill patients, started 24 hours after admission in pediatric intensive care unit (PICU) are accepted to improve health outcomes. Malnutrition prior to admission worsens the prognosis of severely ill children and it will lead to a higher mortality, a longer length of stay, and a higher health cost.

Objective: The main outcome was to investigate the prevalence of hospital malnutrition on admission, discharge, and in-hospital in PICU Sanglah Hospital, Bali during 2015. The secondary outcome was to investigate the association of cost and hospital malnutrition.

Methods: A retrospective study was conducted in PICU Sanglah Hospital, Bali, from January to December 2015.

Patients and participants: Children aged 1 month to 12 years with complete medical records. We assessed the prevalence of hospital malnutrition using WHO Anthro software or WHO AnthroPlus software.

Results: From January to December 2015, there were 477 patients admitted to the PICU and 456 were enrolled in this study. Malnutrition was observed in 72 patients (15.8%) during PICU admission, 56 (17.2%) during discharged, and only 13 (2.9%) suffered from malnutrition during hospitalization. Multivariate analysis showed that malignancy was the only factor associated with in-hospital malnutrition. Malnutrition during admission and discharge were not associated with an increase in the length of hospital stay. But, in-hospital malnutrition was associated with longer length of stay (3.2 vs 14.0 days, p<0.001), and was associated with additional cost of Rp 5,500,000.

Conclusion: Malnutrition was observed in 72 patients during PICU admission, 56 during discharged and only 13 during hospitalization. Hospital malnutrition was associated with additional cost of Rp 5,500,000.


“Complete” loss of brain stem reflexes - not always brain death! Beware of amitriptyline overdose

Abstract

We present a case of “complete” loss of brain stem reflexes following amitriptyline overdose, which mimicked brain death. This case highlights the complexities associated with clinical brain death determination and calls for close attention to details.

Based on previously published case reports, we analyse the relationship with the amitriptyline dose, blood level and timing of neurological recovery. Ours is the fourth case report in literature demonstrating “complete” loss of brain stem reflexes following amitriptyline overdose.

The amount of amitriptyline ingested in these cases (including our case report) ranged from 500 mg to 9 g; the blood concentrations ranged from 1.35 microgram/ml to 3.43 microgram/ml. The neurological recovery seems to start by day two to four with complete neurological recovery by day five to seven.