The effectiveness of noninvasive ventilation in myasthenia gravis patients with respiratory failure in reducing the need of endotracheal intubation and increase extubation outcomes

Abstract

Background: Myasthenia gravis is characterized by muscle weakness and fatigability. The affected muscle are ocular muscle, oropharyngeal muscle, facial muscle, and respiratory muscle. This leads to respiratory failure in myasthenia gravis patients with myasthenic crisis. Noninvasive ventilation has been used to treat patients with hypercapnia respiratory failure and associated with reduction of the need of endotracheal intubation, reduction of complication rate, reduction of hospital stays, and reduction of mortality. In myasthenia gravis patients with respiratory failure, there is no evidence that noninvasive ventilation would reduce those factors. Thus, we studied the effectiveness of noninvasive ventilation in myasthenia gravis patients with respiratory failure in reducing the need of endotracheal intubation and increase extubation outcomes.

Methods: Literature review on PubMed, Elton B. Stephens Co. (EBSCO), Cochrane, and ScienceDirect yield two relevant articles.

Results: Two studies showed that noninvasive ventilation in subject with myasthenia gravis with respiratory failure had better effect.

Conclusion: It is effective to use noninvasive ventilation in subject with myasthenia gravis during their respiratory failure in myasthenic crisis.


Authors: Nadya Farhana, Zulkifli Amin

Carisoprodol intoxication: a comprehensive review

Abstract

Carisoprodol has been widely used as a muscle relaxant agent. In Indonesia, carisoprodol is well-known as carnophene/zenith. Many retailers sell this drug illegally, especially to sex workers to make them feel more relaxed. Due to high incidence of carisoprodol abuse, Drug Enforcement Administration (DEA) categorized it into Schedule IV. Knowledge about pharmacokinetic and pharmacodynamic of carisoprodol are essential to be understood for proper diagnosis and management. Until now, there are only a few case reports about carisoprodol intoxication and no guideline has been published. This article aims to provide an overview about carisoprodol intoxication, starting from the mechanism of action to its management. In the body, carisoprodol is metabolized to meprobamate by CYP2C19 liver enzyme. Diagnosis of carisoprodol intoxication is challenging because carisoprodol and meprobamate have opposite effect. Gastric lavage, administration of flumazenil and bemegride may be effective for acute intoxication case.


Authors: Zulkifli Amin, Steven Zulkifly, Stephen Diah Iskandar

The use of furosemide in critically ill patients

Abstract

Critically ill patients are those with life threatening illness who, without adequate medical interventions, will suffer from severe morbidity and occasionally mortality. One of the most frequent cause of morbidity and mortality in critically ill patients is distributive or vasogenic shock. After liberal fluid resuscitation, an increase in microvascular hydrostatic pressure, fluid accumulation of interstitial compartment, and impaired organ function occur. Normally this phase, called ebb phase, will return to flow phase where inflammatory mediators homeostasis occurs, plasma oncotic pressure restored, diuresis, extravascular fluid mobilized and negative fluid balance occur. In certain group of patients, there is persistent systemic inflammation, plasma leakage, and failure to achieve flow phase spontaneously, which lead to fluid overload and global increased permeability syndrome (GIPS). GIPS causes venous resistance of organs within compartment, resulting in decreased perfusion pressure and organ failure. In this condition, it is necessary to remove the fluid actively and one of the drugs that can be used is furosemide. This literature review will describe what happens in critically ill patients, how furosemide works, what its benefits are in critically ill patients, what side effects and potential toxicities of furosemide.


Authors: Mayang Indah Lestari, Yohannes WH George

Accuracy of calculated creatinine among amputees: case presentation and literature review

Abstract

Dosing vancomycin for patients who do not follow population pharmacokinetics can be challenging. Standard predictive clinical equations do not account for extreme patient characteristics. In particular, serum creatinine is significantly reduced while creatinine clearance is overestimated in patients with amputations. The “missing” body part must be accounted for when executing a dosing regimen for these challenging patients. In addition, health care professionals must judiciously review the patient holistically, practice evidence-based medicine, and consider the overestimation of renal function, when calculating doses for this and other agents. While current literature does not provide a clear consensus for this population, there are several factors to take into consideration when determining the optimal dose in patients presenting to the hospital requiring medications dosed by changes in renal function. We recently had one such case.


Authors: Janay Bailey, Elizabeth Awudi, Charlene Kalani, George Udeani, Joseph Varon, Salim Surani

Sodium bicarbonate buffering for metabolic acidosis does not hasten hemodynamic improvement in septic shock: a retrospective analysis of a 5-year period

Abstract

Objective: Severe metabolic acidosis often occurs in the setting of septic shock and hemodynamic collapse. Acid buffering agents such as sodium bicarbonate are often used to improve acidosis, although the hemodynamic benefit of improving the serum pH is uncertain and has been evaluated only in a few small clinical studies.

Design: A retrospective cohort of patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate.

Setting: A single-center mixed medical-cardiac-surgical intensive care unit.

Patients and participants: 21 patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate. Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate served as a matched control group.

Interventions: The primary endpoint was the change in norepinephrine equivalent (NEEq) dose at 24 and 48 hours after initiation of sodium bicarbonate when compared to non-sodium bicarbonate treated patients. Secondary outcomes included: hospital mortality, the impact of hypocalcemia on vasopressor requirements, and the impact of hypercapnia on vasopressor requirements in sodium bicarbonate treated patients.

Measurements and results: Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate had no difference in the decline of vasopressor requirements than those administered sodium bicarbonate at 24 hours (0.09 μg/kg/min; 95% CI, [-0.23, 0.05], p=0.19) and at 48 hours (0.04 μg/kg/min; 95% CI [-0.11, 0.18], p=0.60). In patients with pH≤7.15, there was no difference in the change in NEEq dose between sodium bicarbonate treated or non-bicarbonate treated patients at 24 hours (0.05 μg/kg/min, 95% CI, [-0.09, 0.11], p=0.69) or at 48 hours (0.19 μg/kg/min, 95% CI, [-0.52, 0.14], p=0.17).

Conclusions: Administration of sodium bicarbonate did not improve vasopressor requirements at 24 or 48 hours, even in patients with a pH less than 7.15. Mortality and vasopressor needs are high in patients with pH less than 7.15 and unaffected by sodium bicarbonate administration.


Authors: John H. Ferguson, Maurice M. Otterstetter, Nicholas JK Tranchida, James DeFoe

Predictors of perceptions of patient safety culture and frequency of event reporting by critical care nurses in Oman: a model-building approach

Abstract

Objectives: This study was conducted to identify the predictors of critical care nurses’ perceptions of patient safety culture and the frequency of event reporting.

Methods: A cross-sectional study design was used. Patient safety culture was assessed using the Hospital Survey on Patient Safety Culture, which was completed by 270 critical care nurses working in two hospitals in Oman.

Results: The results revealed that teamwork within units had the highest positive score (91.8%), followed by organisational learning and continuous improvement (86.3%) and feedback and communication about errors (77.7%). Regression analysis showed that teamwork within units, supervisor/manager expectations and actions promoting patient safety, organisational learning and continuous improvement, management support for patient safety, feedback and communication about errors, teamwork across units, staffing, hospital handoffs and transitions, and patient safety grade were all predictors of the overall perception of patient safety culture among critical care nurses in Oman (R2=0.462, adjusted R2=0.186; F=7.83, p<0.0001). Regression analysis showed that openness in communication, income, non-punitive response to errors, organisational learning and continuous improvement, and feedback and communication about errors were predictors of the frequency of events reporting among critical care nurses in Oman (R2=0.24, adjusted R2=0.043; F=3.41, p<0.0001).

Conclusion: Patient safety culture is an important indicator of the quality of care, and represents one of the key performance indicators in the healthcare setting.


Authors: Qasim Al Ma'mari, Loai Abu Sharour, Omar Al Omari

Eosinopenia as an indicator for organ dysfunction in septic patients

Abstract

Sepsis is one of the most common causes of morbidity and mortality in intensive care unit (ICU).

Objective: To determine the possibility of eosinophil as indicator for organ dysfunctions in sepsis patients and septic shock patients in ICU.

Design: Prospective.

Setting: Intensive care unit (ICU) Wahidin Sudirohusodo Hospital, Makassar.

Participants: Adult sepsis patients admitted to ICU from October to December 2018.

Measurement: Eosinophils count and Sequential Organ Failure Assessment (SOFA) scores were assessed within 24 hours and after 72 hours after patients admitted in ICU. The patients were categorized into non- and organ dysfunction groups based on SOFA scores after 72 hours. Outcomes of the patients then evaluated at day 7.

Results: Thirty four sepsis patients participated in the study. The mean of SOFA scores between non- and organ dysfunction groups were not different within 24 hours after admission but then showed a difference after 72 hours (p=0.558 and p<0.001, respectively). In contrast with non-organ dysfunction patients, after 72 hours the eosinophil count in organ dysfunction group decreased (from 0.51 to 0.15 cells/µl). There was a negative correlation between eosinophil count and SOFA scores at 72 hours (p=0.043; rho: -0.350). In discriminating non-organ dysfunction and organ dysfunction groups, the area under the receiver operating characteristic curve was 0.714. Eosinophils at 0.5 cells/µl (eosinopenia) yielded a sensitivity of 92.8%, a specificity of 66.6%, a positive predictive value of 92.8%, and a negative predictive value of 66,6%.

Conclusion: Eosinopenia levels might be used as an indicator for organ dysfunction in critically ill patients, including sepsis patients, in area where laboratory facility is limited.


Authors: Syafri Kamsul Arif