Association of fluid balance during first 48 hours and length of mechanical ventilation in pediatric intensive care unit


Background: Prolonged mechanical ventilation can increase mortality and morbidity rate. Study shows that positive fluid balance associated with prolonged mechanical ventilation, longer hospital length of stay, and higher mortality rate in acute lung injury. We conducted this study to show the association of fluid balance and duration of mechanical ventilation in the pediatric intensive care unit.

Methods: This was an analytic observational study in children one month to 18 years old who admitted to Pediatric Intensive Care Unit (PICU) Haji Adam Malik General Hospital Medan during April-November 2019. Fluid balance was recorded during first 48 hours in PICU. Bivariate analysis was done to analyse association of fluid balance and length of mechanical ventilation with logistic regression analysis for the mortality.

Results: One hundred and seventy-one children were included in this study. Positive fluid balance was found in 102 children (59.6%) with length of mechanical ventilation mostly under seven days (64.3%). Chi-square test showed significant association between fluid balance and duration of mechanical ventilation (p<0.001). Univariate logistic regression analysis showed that fluid balance had no significant association with mortality, but Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and Pediatric Index of Mortality 2 (PIM2) had significant association with OR 2.6 (1.6-4.4) and 1.05 (1.02-1.08), respectively. Multivariate model also indicated that PELOD-2>8.5 and PIM2>30% showed significant association with mortality (OR 2.6 [1.6-4.4] and OR 1.05 [1.02-1.08], respectively).

Conclusion: Fluid balance was associated with length of mechanical ventilation, but no effect on mortality. Multivariate model showed independent association of PELOD-2>8.5 and PIM2>30% with mortality.

Authors: Andriamuri P. Lubis, Aridamuriany D. Lubis

Left ventricular end-diastolic volume index as a predictor of fluid responsiveness in children with shock

Objective: To identify role of left ventricular end-diastolic volume index as predictor of fluid responsiveness in children.
Design: This was a diagnostic study in children with shock in the Emergency Room and Pediatric Intensive Care Unit of Cipto Mangunkusumo Hospital from June to November 2018. The left ventricular end-diastolic volume index measurements were performed using ultrasonic cardiac output monitor and compared to the increase in stroke volume of ≥15% after fluid challenge as fluid responsiveness criteria. Sample categorized into fluid responsive and non-responsive.
Results: Of 40 subjects, 60 fluid challenge samples were obtained. There were 31 and 29 samples in the fluid responsive and non-responsive group, respectively. There was no significant mean difference in left ventricular end-diastolic volume index in the two groups (p=0.161). The area under the receiver operating characteristic (AUROC) of left ventricular end-diastolic volume index was 40.9% with cutoff value of 68.95 ml/m2. The sensitivity and specificity were 45.16% and 44.83%, respectively. At the left ventricular end-diastolic volume index value of 81.10 ml/m2, the specificity was 72.41% with 22.6% sensitivity.
Conclusion: This study cannot prove left ventricular end-diastolic volume index can act as a predictor of fluid responsiveness in children.

Authors: Ahmad Bayu Alfarizi, Antonius Hocky Pudjiadi, Rismala Dewi

On becoming a COVIDologist: An intensivist tale

In late December 2019, I was made aware of a novel coronavirus, which had been identified as the cause of a cluster of pneumonia and acute hypoxemic respiratory failure in Wuhan, China. As we are now aware, this coronavirus disease 2019 (COVID-19) outbreak became a global pandemic. Over the next several months, I read everything I could about this illness, from basic epidemiology to advance diagnostic and therapeutic methods.

By the end of February of 2020, a series of cases were reported in the United States, and large mass gathering events were cancelled. At that time, I knew I was going to be called upon to take care of these patients in a very short period of time.

Authors: Joseph Varon

Under pressure… Pressure pushing down on me

A 70-year-old male without significant medical history, presented to the hospital after having been trapped under a piece of industrial equipment for several hours. In addition to multiple orthopedic fractures and compartment syndrome requiring left upper extremity fasciotomies, he was found to have rhabdomyolysis and renal failure. The patient was aggressively resuscitated with crystalloid fluids. He arrived to the Surgical Intensive Care Unit (SICU) intubated and was ultimately started on continuous veno-venous hemodialysis (CVVHD) for metabolic derangements including hyperkalemia. Tube feeds were started on hospital day 1 and the patient was noted to have been having good bowel function.

Authors: Avi Ruderman, Brian T. Wessman

Lung injury prediction score as a predictor of acute respiratory distress syndrome in intensive care unit


Background: Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxemia and bilateral infiltrates in the lung after a triggered injury. A major obstacle in ARDS prevention is the identification of patients at risk of ARDS. The goal of this study was to assess the validity of lung injury prediction score (LIPS) as a predictor of ARDS in the intensive care unit (ICU).

Patients and methods: This is a retrospective observational study conducted in the ICU of Sanglah General Hospital (Bali, Indonesia) in 2019 with 451 subjects were eligible after a systematic random sampling method. Receiver operating characteristics (ROC) analysis was used to assess the ability of LIPS to predict ARDS and determine the best cutoff point for LIPS in predicting ARDS.

Results: The area under ROC curve (AUC) value was 0.86 (95% CI 0.81-0.91). The best cutoff point was at LIPS ≥5 (sensitivity 85.71%, specificity 80.77%). From a cross tabulation calculation, we obtained a relative risk of 18.6 (95% CI 7.4-46.77). A logistic regression analysis obtained an odds ratio of 1.71 (95% CI 1.45-2.03).

Conclusion: LIPS is valid for predicting the incidence of ARDS in ICU patients. It can be used as a screening tool to identify those with a high risk of developing ARDS.

Authors: Tjokorda Gde Agung Senapathi, Made Wiryana, I Made Gede Widnyana, Christopher Ryalino, Budi Hartono

The use of COVID-19 IgM rapid test in the setting of negative RT-PCR to diagnose infection by SARS-CoV-2: A challenging case


In December 2019, a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) caused an outbreak of respiratory disease in Wuhan, China, that quickly spread to other countries causing a global pandemic. Although the reverse transcriptase polymerase chain reaction (RT-PCR) test for SARS-CoV-2 infection has become the standard method of diagnosis, this test has limitations that cause false negative results. The sudden onset, and spread of this virus, has created an urgency to find reliable screening and diagnostic tools to identify infected patients, prevent further transmission, and provide treatment for these patients. A rapid and accurate diagnostic tool, the COVID-19 combined IgG and IgM “Rapid” test can detect these antibodies against SARS-CoV-2 using a finger prick blood sample detecting infection in 15 minutes. We report the use of the COVID-19 IgM Rapid Test in the presence of high clinical suspicion, along with typical chest computed tomography findings suggestive of COVID-19 infection, in a patient who tested negative twice for the nasopharyngeal swab specimen RT-PCR test.

Authors: Elizabeth Gamboa, Melanie Duran, Alan Araiza, Daryelle Varon, Mariya Mohiuddin, Joseph C Gathe Jr, Joseph Varon

COVID-19-induced hepatic encephalopathy: A case report


By the end of December 2019, a single stranded ribonucleic acid (RNA) virus, Coronavirus, was said to be responsible for an outbreak of respiratory infections of unknown origin in Wuhan, China. Globally, this virus has caused over 160,000 deaths and is expected to increase as the pandemic continues. The majority of patients with the coronavirus disease 2019 (COVID-19) infection present symptomatically with fever, shortness of breath, or cough; however, given that the Coronavirus targets the angiotensin converting enzyme 2 receptors (ACE2), it has been suspected that the virus also exhibits neuroinvasive effects. We present a case of a 32-year-old man with a one-week history of progressive shortness of breath, myalgias, arthralgias, fever peaks, who tested positive for COVID-19 and developed acute hepatic encephalopathy with altered mental status.

Authors: Elizabeth Gamboa, Diego Montelongo, Hussein Berjaoui, Daryelle S. Varon, Joseph C Gathe Jr, Joseph Varon