Effects of N-acetylcysteine on high-sensitive C-reactive protein level and wall motion score index after ST-segment elevation myocardial infarction and fibrinolytic therapy: A randomized trial

Authors: Trisulo Wasyanto, Savithri Indriani, Ahmad Yasa

Abstract

Objective: To determine the effect of N-acetylcysteine (NAC) on the high-sensitive C-reactive protein (hsCRP) level and wall motion score index (WMSI) in patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy.

Methodology: We performed a randomized pre-post study in consecutive patients who received fibrinolytic therapy for STEMI at Dr. Moewardi Hospital from July through August 2018. Patients were randomly allocated to receive NAC 600 mg 3 times daily for 3 days (treatment group) or no NAC (control group). Patients underwent pre- and post-treatment hsCRP measurement and echocardiographic examination with calculation of the WMSI. Pre- and post-therapy differences in clinical characteristics were analyzed within and between groups using independent sample t-, Mann-Whitney, paired t-, and Wilcoxon tests as appropriate.

Results: Thirty-two patients were analyzed. The control and treatment groups included 15 (mean age 58.27±8.07 years) and 17 (mean age 55.24±10.19 years) patients, respectively. There were significant between-group differences in hsCRP levels (p=0.001) and WMSIs (p=0.005) after therapy. In the control group, the median post-therapy hsCRP and WMSI were 151.50 mg/l (range 42.50-285.20) and 1.3 (range 1.1-1.7), respectively, compared to 14.90 mg/l (range 3.60-266.80) and 1.2 (range 1.0-1.5), respectively, in the treatment group.

Conclusion: Patients with STEMI who received NAC (600 mg 3 times daily for 3 days) in addition to fibrinolytic therapy had lower post-intervention hsCRP levels and WMSIs than patients who received fibrinolytic therapy alone. These findings will provide a therapeutic option for the successful management of patients with AMI.

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Intravenous thiamine as an adjuvant therapy for hyperlactatemia in septic shock patients

Authors: Nur Fazlina Harun, Saw Kian Cheah, Aliza Mohamad Yusof, Chee Lan Lau, Azlina Masdar, Siti Nidzwani Mohamad Mahdi, Nurlia Yahya, Norma Mohamad, Raha Abdul Rahman

Abstract

Objective: To assess the effectiveness of intravenous (IV) thiamine in reducing hyperlactatemia in septic shock patients.

Design: Prospective, randomized controlled trial.

Setting: General intensive care unit (GICU), Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur.

Patients and participants: Adult patients with septic shock and hyperlactatemia (lactate ≥2 mmol/l).

Interventions: IV thiamine 200 mg thrice daily for 3 days.

Measurements and results: A total of 72 patients were recruited into the study. Seven patients died within 24 hours of study commencement and were dropped out. Patients were randomized into the thiamine group (TG) who received IV thiamine 200 mg diluted in 50 ml of normal saline, or placebo group (PG) who received 50 ml of normal saline infusion over 30 minutes. Arterial blood lactate samples were collected at time of enrolment, after 6, 12, 18, 24, 48, and 72 hours of study drugs administration. Relative lactate changes over 24 hours, duration of weaning off vasopressors, Sequential Organ Failure Assessment (SOFA) score changes over 72 hours, ICU length of stay (LOS) and mortality rates were compared between groups. There were no significant differences in the relative lactate changes (TG: 37.5% [4.7-59.1] vs PG: 47.8% [29.1-70.7], p=0.091), duration of vasopressors being weaned off (TG: 75.5 [48.0-131.25] vs PG: 88.0 [48.0-147.0]), SOFA score changes (TG: 3.0±3.41 vs PG: 2.7±3.3), ICU LOS (TG: 5.0 [4.0-11.0] vs PG: 6.0 [3.0-12.0]), and ICU mortality rate (TG: 14 [43] vs PG: 12 [37]). Multivariate logistic regression test showed that baseline lactate level was an independent predictor for mortality (p=0.044).

Conclusion: Intravenous thiamine did not show significant improvement in relative lactate changes, time for shock reversal, SOFA scoring, ICU LOS, and mortality rate in septic shock patients with hyperlactatemia. However, baseline lactate level was shown to be an independent predictor for ICU mortality.

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Sigmoid volvulus: An image telling the story

Authors: Gerardo Rivera, Salim Surani, Joseph Varon

A 77-year-old gentleman, with past medical history of dementia and psychosis, presented to the emergency department with a chief complaint of abdominal distention. X-ray imaging of the abdomen revealed air filled distended loops of large bowel (Figures 1A and 1B). Computerized tomography (CT) revealed marked dilatation of the large intestine, from the cecum to the sigmoid colon where there is a beak-shaped transition as well as multiple air fluid levels without free air (Figures 2a and 2b). A bedside colonoscopic decompression was performed with resolution of the volvulus.

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Comparison of outcome between percutaneous dilatation tracheostomy and surgical tracheostomy in Intensive Care Unit of Dr. Wahidin Sudirohusodo Hospital Makassar

Authors: Syafri K. Arif, Andy Setiawan, Hisbullah, Faisal Muchtar, Haizah Nurdin

Abstract

Percutaneous dilatation tracheostomy (PDT) has been widely used in Indonesia, yet no study to evaluate the outcome of PDT compared to surgical tracheostomy (ST) is available.

Objective: This study was aimed to evaluate the use of PDT in Indonesia.

Design: Non-randomized comparative retrospective study.

Setting: Intensive Care Unit of Wahidin Sudirohusodo Hospital Makassar.

Patients: Eighty-four patients aged 15 to 90 years, undergone tracheostomy during 2016 to 2017 were evaluated.

Measurements and results: Samples were evaluated in terms of surgical duration, blood loss volume, mortality, and complication rates such as post-operative bleeding, pneumothorax, subcutaneous emphysema, stomal infection, tracheal stenosis/malacia, and unintended fistula formation. Collected data were analyzed with SPSS version 22. Mean operative duration of PDT (18.3 minutes) were significantly faster than ST (40.2 minutes) (p<0.05), accompanied by significant reduction of mean blood loss 13.6 ml compared to 21.1 ml in ST group (p<0.05). A total of 9 complications (18.8%) found in ST group and 5 (13.9%) in PDT group, with stomal infection was the most common complications. Mortality rate were 52.8% in PDT group and 45.8% in ST group (p>0.05), none associated with the procedure itself.

Conclusion: It is suggested that PDT is a superior technique in placement of tracheostomy canula.

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Case report: a fatal case of severe pancreatitis associated with rhabdomyolysis

Authors: Saw Kian Cheah, Mohamed Izzad bin Isahak, Wan Rahiza Wan Mat, Shereen Suet Ping Tang, Rufinah Teo, Aliza Mohamad Yusof, Raha Abdul Rahman

Abstract

Background: Rhabdomyolysis is an uncommon presentation associated with severe acute pancreatitis (SAP). Patients usually present late and asymptomatic, thus it carries poorer clinical outcome and higher mortality rate.

Case report: We report a case of SAP in a 42-year-old man who presented with persistent epigastric pain, elevated serum amylase, and characteristics of acute pancreatitis on the contrast-enhanced computed tomography of the abdomen. Investigations revealed persistent hyperkalemia and severely elevated creatinine kinase in the presence of acute kidney injury, which led to the uncommon possibility of diagnosing severe rhabdomyolysis. He suffered complications of intra-abdominal hypertension, feeding intolerance, severe ARDS and multi-organ failure. He succumbed to death after a month despite aggressive intensive care therapies and support.

Discussion: The actual pathophysiology of rhabdomyolysis in SAP is complex. It is postulated that acute inflammation of pancreas causes ATP-dependent proton pump dysfunctions leading to skeletal muscle cells injury and therefore, rhabdomyolysis.

Conclusion: Coexistence of rhabdomyolysis with SAP have higher risk for fatality, therefore, its presence allows early triage, early aggressive resuscitation and intensive care management.

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When you know too much for your own good: The Boston-Varon syndrome

Authors: Joseph Varon, James Boston

It has been stated that knowledge is everything. However, sometimes this can actually be counterproductive. For example, the so-called “medical students' disease” (or second-year syndrome, intern's syndrome), has been described as a condition in medical students, who perceive themselves to be experiencing the symptoms of a disease that they are studying. This syndrome is associated with an intense fear of contracting the disease in question.

An identical syndrome could potentially be ascribed to those who care for patients, and in whom on of their family members suffer a condition that requires diagnosis. Here, we describe a variant of such syndrome, for which we have coined the term Boston-Varon Syndrome (BVS).

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McConnell’s sign is not specific for acute pulmonary embolism – A case report

Authors: Mohamad Iqhbal Bin Kunji Mohamad, Mohd Fazrul Bin Moktar, Julina @Azimah Mohd Noor, Nur Abdul Karim, Izzat Bin Ismail, Abdul Halim Bin Sanib, Mohd Amin Mohd Mokhtar, Safreeda SF Salim

Abstract

Since 1996, McConnell’s sign, defined as right free wall hypokinesia with apical sparing, described as one of the most specific echocardiographic finding for acute pulmonary embolism. It was incorporated in the standard teaching and text book as a tell-tale sign for the condition. This is a case report of a patient presented with chest pain and presyncope with markedly raised D-dimer and suspicious electrocardiogram finding. The bedside focused cardiac ultrasound revealed the classical McConnell’s sign. However, the computed tomography pulmonary angiogram for pulmonary embolism was negative. The patient was subsequently diagnosed as pulmonary hypertension secondary from chronic methamphetamine abuse. This case highlights that McConnell’s sign is not specific for acute pulmonary embolism. It is also important to stratify patient according to a validated clinical probability score for pulmonary embolism before initiating definitive acute treatment.

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Hydrocortisone, vitamin C, and thiamine as treatment of septic shock combined with cardiogenic shock: a case report and literature review

Authors: Temima Saltzman, Adel Hanna, Shan Wang

Abstract

Objective: To determine whether the concomitant administration of vitamin C, hydrocortisone, and thiamine improves sepsis-related organ failure assessment (SOFA) score and mortality in a patient with septic and cardiogenic shock, multiple organ dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), gram negative bacteremia, cardiomyopathy, disseminated intravascular coagulation (DIC), and 95% mortality on presentation.

Design: A case report and literature review.

Setting: Surgical Intensive Care Unit at NYU Winthrop Hospital.

Patient: Patient with 95% mortality received appropriate treatment for septic and cardiogenic shock with no clinical improvement.

Intervention: Hydrocortisone 50 mg intravenous push (IVP) every 6 hours for four days, vitamin C 1,500 mg IV every 6 hours for four days, and thiamine 200 mg intravenous piggyback (IVPB) every 12 hours for four days.

Conclusion: Our patient had a remarkable survival of what was thought to be indefinite mortality with the intervention of vitamin C, hydrocortisone, and thiamine. The administration of the vitamin C protocol warrants a randomized controlled trial to change management of septic shock and mortality. We are very optimistic that it will show similar results yielding a significant decrease in mortality rates in patients with septic shock.

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Short-term complications of ultrasound-guided bedside peripherally inserted central catheter in the Intensive Care Unit: 1 year experiences

Authors: Se Heon Kim, Young Hoon Sul, Yook Kim, Joong Suck Kim, Moon Sang Ahn

Abstract

Objectives: Critically ill patients in the intensive care unit (ICU) need central catheter for various reasons, such as long-term intravenous access, nutrition, antibiotic usage, or chemotherapy. Generally, peripherally inserted central catheter (PICC) lines are the most commonly used type of intravenous access meant for long-term use. But, moving critically ill patients from the intensive care unit to the interventional radiology room (IRR), where PICC installation is usually performed, can disrupt ongoing critical care and may be in dangerous situation. Recently, several articles have reported the successful clinical implementation of bedside PICC installation under ultrasound (US) guidance. We aimed to evaluate and report the 1 year experiences of bedside PICC installation under US guidance in ICU by analysis short-term complications.

Methods: We performed a retrospective cohort study of 123 PICCs placed in adult ICU at a tertiary care academic medical center between October 2017 and September 2018. The data were analyzed to identify short-term complications, such as malposition of catheter tip, infection, and occlusion.

Results: Among 123 PICCs, 52 cases were performed in the IRR and 71 cases were performed in the ICU. The overall complications were in 18 cases (14.6%). Malposition of catheter tip was found in 12 cases (9.8%), infection was found in 4 cases (3.3%), occlusion was found in 2 cases (1.6%). Complication rate was higher in the ICU group (18.3%) than the IRR group (9.6%). Malposition was found in 11 cases in the ICU group and 1 case in the IRR group. Infection was found in 2 cases in both groups. Occlusion was found in 1 case in both groups.

Conclusions: The incidence of malposition of catheter tip as short-term complication is higher in the case of performing bedside PICC installation under ultrasound in ICU than in IRR.

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

Authors: Nadya Farhana, Zulkifli Amin

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.

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