Anesthesia and intensive care management in acute ischemic stroke patient

Abstract

Acute ischemic stroke is a brain functional disorder, which cause high disability and mortality rate worldwide, the second most common cause of dementia, and the third leading cause of death. It has enormous clinical, social, and economic implications and demands a significant effort from both basic scientists and clinicians in the quest for understanding the underlying pathomechanisms and producing suitable preventive measures and successful therapies. Management of acute ischemic stroke has been revolutionized by the introduction of several interventions, such as prehospital and stroke unit care, intravenous tissue plasminogen activator therapy within 4.5 hours of stroke onset, aspirin therapy within 48 hours of stroke onset, decompressive craniectomy for supratentorial malignant hemispheric cerebral infarct, and more recently endovascular therapy for anterior circulating stroke. Also, special attention in management of vital systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose. In line with this, the role of neuroanesthesiologists and neuro critical care in managing acute ischemic stroke become more prominent.


Do Asian physicians manage hypertensive crisis properly? A Southeast Asia survey analysis

Abstract

Purpose: Hypertension remains a common cause of morbidity and mortality worldwide, and proper management can prevent death. Over the last few decades, several changes in definitions, clinical manifestations, and management have occurred. We aimed to investigate the extent of knowledge about these changes, as the pertain to acute elevations of blood pressure among physicians in Southeast Asia.

Methods: A cross-sectional survey was created and validated. The survey included 25 questions about the definitions of hypertensive urgencies and emergencies, clinical presentations, ideal rate of blood pressure reduction, and other questions. Surveys were distributed at the Asia Pacific Symposium held in Indonesia in August 2017. Descriptive analysis was conducted using IBM SPSS Statistics™ version 25.0 (IBM Corporation, Armonk, NY).

Results: A total of 145 surveys were completed by physicians from India, Indonesia, South Korea, Philippines, Singapore, and Sri Lanka. Of them, only 49.6% (n=72) knew the normal blood pressure cut-off limits, and 19.3% (n=28) did not recognize the differences between hypertensive urgencies and emergencies. Moreover, 53.7% (n=78) of respondents was not aware that hypertensive urgency can be completely asymptomatic. Sixty-four point eight percent (n=94) indicated that acute cerebrovascular accidents were the most common end-organ damage from hypertensive emergencies. In addition, only 44.1% (n=64) were aware of the ideal rate of blood pressure reduction, and 50.3% (n=73) considered sublingual nifedipine as an appropriate choice in hypertensive crisis management.

Conclusions: A significant percentage of physicians in Southeast Asia lack knowledge about hypertensive crisis definitions, clinical presentations, and management.


Corticosteroids and gastrointestinal bleeding in critical care: a systematic review and meta-analysis

Abstract

Background: Current belief suggests that patients receiving corticosteroids have an increased risk of bleeding from stress ulceration and that these patients should receive stress ulcer prophylaxis. This issue is important as many ICU patients receive corticosteroids and the pharmacologic agents used for stress ulcer prophylaxis are associated with adverse events.

Aim: The goal of this systematic review and meta-analysis was to compare the rate of clinically significant (overt) gastrointestinal (GI) bleeding in critically ill patients receiving corticosteroids versus placebo.

Methods: We searched PubMed, Embase, and the Cochrane database from inception through December 2018. In addition, the bibliographies of selected articles were reviewed for relevant studies and included if inclusion criteria were met. Included studies were randomized, placebo-controlled and blinded studies that compared treatment with corticosteroids for any indication in a patient population that included only ICU patients. Primary outcome of interest was rate of clinically significant GI bleeding in patients treated with corticosteroids versus placebo. Results were expressed as risk ratio (RR) with accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and risk of bias were explored. In addition, we did a subgroup analysis according to the use of “low-dose” (<400 mg hydrocortisone or equivalent/day) versus “high-dose” corticosteroid.

Results: Thirty-five studies, which enrolled 16,659 patients, met inclusion criteria and were analyzed. Significant GI bleeding was recorded for 355 patients (overall rate of 2.1%). Summary data demonstrated no difference in the risk of GI bleeding between those treated with corticosteroids versus placebo (RR 1.08; 95% CI 0.88-1.33; p=0.46) with minimal heterogeneity between studies (Q statistic p=0.86, I2=0%). Similarly, there was no significant difference in the risk of GI bleeding in either the low (RR 1.04; 95% CI 0.78-1.38) or the high dose groups (RR 1.13; 95% CI 0.84-1.53) and in those studies at low risk of bias (RR 1.16; 95% CI 0.91-1.49) and those at a high risk of bias (RR 0.88; 95% CI 0.6-1.28).

Conclusion: This meta-analysis did not identify a clinically significant difference in the rate of overt GI bleeding in critically ill patients receiving corticosteroids as compared to placebo. The role of stress ulcer prophylaxis in these patients remains uncertain.


The effect of N-acetylcysteine on the myeloperxidase and Tei index in patients with acute myocardial infarction

Abstract

Bacground: Myeloperoxidase (MPO) is a strong oxidant and toxic to microorganisms with excess production causing tissue damage. We aimed to determine the effect of N-acetylcysteine (NAC) 600 mg orally 3 times a day for 3 consecutive days on MPO levels and left ventricle myocardial performance index (LVMPI/Tei index) in ST elevation myocardial infarction (STEMI) patients treated with fibrinolytics.

Methods: Pre- and post-design, single blind experimental randomized trial, conducted on 32 patients with STEMI at Intensive Cardiovascular Care Unit (ICVCU). The subjects were divided into 2 groups: 17 patients received 600 mg t.i.d NAC for 72 hours and 15 controls. MPO levels before and after 72 hours and Tei index 72 hours after NAC therapy were measured. Statistical analysis of MPO level and Tei index were analyzed with SPSS 22. Tei index was measured using the pulsed wave Doppler (PWD) and tissue Doppler imaging (TDI).Results: NAC administration showed decrease in the marker of MPO (112.76±57.28 vs 180.40±69.03, p=0.001) and delta MPO (-50.15±46.62 vs 12.06±108.65) 72 hours after NAC therapy compared with control. NAC improved the LVMPI value compared to the control group. Tei index examination using PWD (0.39±0.11 vs 0.49±0.08, p=0.005) and that using TDI (0.41±0.08 vs 0.57±0.08, p=0.001) showed improved values for NAC administration than those with controls.Conclusion: NAC 600 mg orally 3 times a day for 3 consecutive days can reduce MPO levels and improve diastolic function by decreasing LVMPI values.


The effect of oral N-acetylcysteine on galectin-3 and global longitudinal strain in patients with acute myocardial infarction

Abstract

Objective: Galectin-3 (Gal-3) plays a big role in the development of cardiac fibrosis; however, its role in remodeling after acute myocardial infarction (AMI) has not received sufficient attention. Post-AMI measurements of global longitudinal strain (GLS) are beneficial in providing information about infarct area and remodeling. We aimed to determine the effect of N-acetylcysteine (NAC) on Gal-3 and GLS in AMI.

Design: This was a randomized, single-blind study with pre- and post-treatment evaluations performed from May 1 to August 31, 2018.

Setting: Dr. Moewardi Hospital, Indonesia

Patients: ST elevation myocardial infarction (STEMI) patients who received fibrinolytic therapy were randomly allocated to NAC and control groups.

Interventions: A total of 32 STEMI patients were administered fibrinolytic therapy (17 patients were administered standard therapy plus 600 mg NAC orally three times a day for 72 hours and 15 patients were administered standard therapy plus placebo as the control). Gal-3 samples were taken during admission and at 72 hours in both groups, while GLS measurement was only performed 72 hours after admission.

Measurements and results: Gal-3 levels in the NAC and control groups at admission were not significantly different; however, levels were significantly different after 72 hours (p=0.017). After comparing Gal-3 levels during admission and at 72 hours, the NAC group showed significant differences between Gal-3 levels at the time of admission and at 72 hours (p=0.0001); no difference was found in the control group. There were also significant intergroup differences in Gal-3 level changes (p=0.014). In the NAC group, a better and significantly different 72-h GLS value was obtained from that in the control group (p=0.023).

Conclusion: Supplementary therapy with NAC can reduce Gal-3 levels and GLS in AMI patients receiving fibrinolytic therapy.


Analysis of sepsis and septic shock 3- and 6-hour management at resuscitation room in Dr. Soetomo General Hospital

Abstract

Objective: To provide a record of the implementation and outcome of surviving sepsis campaign 2016 at Dr. Soetomo General Hospital, Surabaya, Indonesia, such as 3- and 6-hour sepsis bundle compliance as a baseline and the Sepsis-related Organ Failure Assessment (SOFA) score after 48 hours of treatment. SOFA values were used to predict mortality in the hospital.

Design: This was an observational experimental study that used cross sectional design.

Setting: Resuscitation room in Dr. Soetomo General Hospital.

Patients and participants: A purposive sample was taken of patients older than 17-year-old suspected with sepsis or septic shock according to diagnosis criteria from Surviving Sepsis Campaign (SSC) 2016. Thirty-two patients, consist of 24 male and 8 female patients were included.

Interventions: After patients were suspected of sepsis or septic shock according to diagnosis criteria from SSC 2016, they were treated with 3- and 6-hour sepsis bundle, then the data were collected with questionnaire.

Measurements and results: We found 75% of patients received a 3-hour sepsis bundle in <3 hours, and 50% of patients had 6-hour sepsis bundle in <6 hours. The compliance rate of 3- and 6-hour sepsis and septic shock bundles reached 46.88%. SOFA scores before and after 48-hour management of sepsis had a significant increase with p=0.001 (p<0.05).

Conclusions: There were significant decreasing of SOFA values in baseline and 48 hours after the management of sepsis and septic shock in 81.25% patients (n=26). This result suggests that management of sepsis based on SSC 2016 contribute to the improvement of the patient's condition and better prognosis.


Correlation between zinc plasma level to inflammation response of patient with ventilator in pediatrics intensive care unit

Abstract

Objective: Critical conditions arise when there is a threat or ongoing organ failure that disrupts the balance of the body's oxygen and physiological needs. Patients often require help, such as endotracheal intubation procedures, mechanical ventilation, and renal or liver replacement therapy, in place of impaired organ function. Usually, complications are more common in children than in adults. Zinc is one of the micronutrients that plays a vital role as an antioxidant and the role of defense immune modulators against systemic inflammatory response syndrome (SIRS). Outcome patient with ventilator depends on SIRS response to the disease. Meanwhile the study about zinc supplementation in Pediatric Intensive Care Unit (PICU) is limited. The main objective of this study was to look at the correlation of plasma zinc levels with inflammatory responses in children of 1-12 years old with ventilator in pediatric intensive care unit.

Design and setting: This study was prospective study in Sanglah General Hospital, Denpasar and was calculated by Pearson analysis to determine the correlation of variables plasma zinc with levels of pro-inflammatory cytokines interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) and continued by general linier model analysis.

Results: More than 70% sample was insufficiency zinc for the first 24 hours and after 72 hours, respectively. Correlation between plasma zinc and pro-inflammatory cytokines were TNF-α; p<0.001 r: -0.91, and IL-6; p=0.013, r: -0.48 in 24 hours, and IL-6; p>0.05 r: 0.011, and TNF-α; p<0.01 r: 0.659 in 72 hours.

Conclusions: There were significant correlation in TNF-α and IL-6 measurement between zinc plasma insufficiency with pro-inflammatory cytokines in the first 24 hours and significant correlation in TNF-α in 72 hours. Therefore, zinc supplementation in 72 hours from patient admission to PICU may have important role to reduce morbidity in PICU.