Vasopressor dependency index: a quick prognostic parameter of septic shock patient in emergency and intensive care unit in remote area

Authors: Imamuddin Arif Wicaksono, Arie Utariani, Kuntaman

Abstract

Objective: The aim of the this study was to find out the outcome differences in septic shock patients based on the vasopressor dependency index (VDI) value at Dr. Soetomo General Hospital Surabaya.

Design: This was an analytical observational research.

Setting: Resuscitation Room of Dr. Soetomo General Hospital Surabaya from March to May 2019. This study was approved by the Research Ethics Committee of Dr. Soetomo General Hospital Surabaya.

Patients and participants: The inclusion criteria was septic shock patient who met sepsis-3 criteria. There were 44 samples in the inclusion criteria.

Interventions: Samples were taken by consecutive sampling. VDI was measured starting from 10 minutes, 1 hour, 6 hours, 12 hours, 24 hours, and 48 hours after the treatment of vasopressor drug.

Measurements and results: The most common causes of sepsis was pneumonia (47.7%). Septic shock patients were given norepinephrine (80.0%) as the first line vasopressor drug. There were patient outcome differences within 7 days of treatment based on the VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variable to the patient outcome (p=0.034). The VDI value threshold of the 24th hour was 0.176/mmHg (81.8% sensitivity; 85.2% specificity; 95% CI 0.818-1.000; p=0.000) and of the 48th hour was 0.150/mmHg (88.9% sensitivity; 92.6% specificity; 95% CI 0.859-1.000; p=0.000).

Conclusion: There were significant differences in septic shock patient's outcome in the first 7 days of treatment based on VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variables to the patient outcome (p=0.034). The threshold of VDI at the 24th hour was 0.176/mmHg. The threshold value of VDI at 48th hour was 0.150/mmHg.

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Venous-arterial CO2 difference to arterial-venous O2 content difference ratio as marker of resuscitation in pediatric septic shock

Authors: Yos Kowara, Arie Utariani, Bambang Pujo Semedi, Purwo Sri Rejeki

Abstract

Objective: Sepsis is still a major cause of mortality in pediatric intensive care units. During initial resuscitation, central venous oxygen saturation (ScvO2) and/or lactate level have become a standard monitoring target nowadays. Carbon dioxide (CO2) partial pressure difference between central vein and artery (Pv-aCO2) has also been recommended as an additional marker to identify persistent global hypoperfusion. Recently, the Pv-aCO2/Ca-vO2 ratio, which represents respiratory quotient, is presumed to be superior in detecting anaerobic metabolism.

Design: Single center observational analytic research with cross-sectional study.

Setting: Resuscitation Room at academic hospital.

Patients and participants: Twenty-four pediatric patients with septic shock, aged 2 months to 12 years old.

Interventions: Patients were resuscitated at the Emergency Department of Dr. Soetomo General Academic Hospital, Surabaya. Initial first hour therapy included oxygenation, antibiotic administration, fluid bolus, and catecholamine titration. Central venous catheter was inserted in all patients through subclavian or jugular veins.

Measurements and results: Lactate was measured in the first and third hour after patient arrival. Arterial and central vein blood gas analysis was performed concurrently at the third hour. Patients were followed up after 48 hours to assess outcome. Pv-aCO2/Ca-vO2 ratio was more effective compared to ScvO2 and lactate clearance in predicting the 48-hour mortality rate (p 0.047). The cutoff value of the Pv-aCO2/Ca-vO2 ratio of 1.54 had the highest sensitivity and specificity to represent global hypoxia in pediatric patients with sepsis.

Conclusion: Pv-aCO2/Ca-vO2 ratio is a useful marker in predicting mortality in pediatric patients with septic shock.

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Prediction of respiratory complications guided by Clara cell protein CC16 in plasma in polytrauma patients

Authors: Kamel Abd El Aziz Mohammed Abd Allah, Moataz Mohamed Ibrahim Aly, Ibrahim Mohamed Atia, Samir El Hadedy Tawfik, Khaled Farid Mohamed Hassan

Abstract

Objective: To evaluate the value of serum levels of Clara cell protein (CC16) as a diagnostic and prognostic utility in patients with polytrauma and relate these levels to respiratory complications compared to plasma levels of healthy control group.

Subjects and methods: A prospective cohort study was carried out on one hundred and fifty patients with polytrauma (blast, blunt, and penetrating) who admitted to Intensive Care Units of Maadi and Kobry El Kobba Hospitals, Cairo, Egypt, from June 2016 and June 2019. Full history taking, clinical examination, radiology investigations, laboratory investigations, CC16 protein and other inflammatory biomarkers were investigated.

Results: There was no statistically significant difference between both groups as regarding age (p=0.09), comorbid conditions (p>0.05), Glasgow coma scale (p=0.09), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p=0.07) and abbreviated injury scale (p=0.08). Along 5 days there was a significantly higher C-reactive protein (CRP) level, neutrophil-lymphocyte ratio in Group I. PO2 level was significantly higher in the first 2 days in Group II than Group I. Chest computed tomography (CT) scan revealed the presence of lung contusion in 30 patients, hemothorax in 20 patients, and pneumothorax in 25 patients, all in Group I. Also, there was a statistically significant difference on day 0 between both groups with much higher serum CC16 in Group I than Group II, while on day 3 the difference was insignificant. Whereas, respiratory complications were significantly higher serum and broncho alveolar lavage (BAL) level of CC16 on day 3, while this difference was insignificant on day 0.

Conclusions: These findings showed that we may benefit from detecting serum CC16 levels in polytrauma victims in prediction of respiratory complications.

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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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