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


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.

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

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


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.

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

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

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).

Authors: Joseph Varon, James Boston

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


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.

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

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


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.

Authors: Temima Saltzman, Adel Hanna, Shan Wang

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


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.

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

Anesthesia and intensive care management in acute ischemic stroke patient


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.

Authors: Hamzah, Prananda Surya Airlangga, Abdulloh Machin, Nancy Margarita Rehatta

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


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.

Authors: Abbas Alshami, Johanan Luna, America Avila, Salim Surani, Joseph Varon

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


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.

Authors: Paul E. Marik, Mit P. Patel, Joseph Varon

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


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.

Authors: Trisulo Wasyanto, Ahmad Yasa, Nuka Meriedlona

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


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.

Authors: Trisulo Wasyanto, Akhmad Jalaludinsyah, Ahmad Yasa

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


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.

Authors: Arie Utariani, Bambang Pujo Semedi, Rizki Anestesia, Hamzah, Eddy Rahardjo, Elizeus Hanindito

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


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.

Authors: Dyah Kanya Wati, Lanang Sidiartha, Ketut Tunas, Andrie Setiawan

Lactic acid’s role in sodium hypertonic lactic solution as a neuroprotector measured from the level of ATP, MCT-1 and necrosis area in intracerebral hematoma rats model


Objective: To discover the role of hypertonic sodium lactate (HSL) as the energy source, which in turn will act as a neuroprotector, by measuring adenosine triphosphate (ATP) level, monocarboxylate transporter 1 (MCT-1) and the extent of the necrotic areas.

Design: This was an experimental study that used randomized post-test only control group design.

Setting: Experimental Animal Care Unit Universitas Gadjah Mada.

Patient and participant: 32 white mice of Rattus norvegicus.

Intervention: After the protocol of this study was approved by the research ethic committee, 32 rats were randomly divided into two groups: HSL group (n=16) and NaCl 3% group (n=16) as the control group. Both groups were anesthetized using conversion-dose pentothal.

Results: ATP level in HSL group was higher compared to the control group (p=0.031). MCT-1 in HSL group was also higher than the control group (p=0.010). Necrotic areas were less extensive in the HSL group than the control group (p=0.000). Lactate levels at minute 30 (T30) and minute 360 (T360) increased in the HSL group, while increasing in the control group up to T30, then decreased gradually until T360.

Conclusion: Exogenous lactate in solution has effect as a neuroprotective of brain in the intracerebral hemorrhage (ICH).

Authors: Hamzah, Nancy Margarita Rehatta, Tatang Bisri, Siti Chasnak Saleh, Arie Utariani

End-of-life care (EOLC) in Jordanian critical care units: Barriers and strategies for improving


Background: End-of-life care (EOLC) is a pivotal element of work in ICUs and for critical care nurses, thus, it is considered one of the top research priorities recently as number of admission ICUs increasing and high percentage of deaths also.

Objective: This study was conducted to explore the obstacles of EOLC and strategies for improvement from nurses' perception.

Methods: The questionnaire, that was developed by Beckstrand and Kirchhoff (2005), was used to collect data from 163 critical care nurses from different hospitals.

Results: Two hundred questionnaires were distributed. One hundred and sixty-three questionnaires were completed and returned with response rate 81.5%. The majority of the participants were male nurse 104 (63.8%), with bachelor degree 153 (93.9%), working in adult ICU 105 (64.4%), as bedside nurse 141 (86.5 %). The highest obstacles from the nurses’ perception were family and friends who continually call the nurse wanting an update on the patient’s condition rather than calling the designated family member for information (mean=4.07). Furthermore, the highest three supportive behaviors from the nurses’ perception were physicians agreeing about direction of patient care (mean=3.96), family members accept that patient is dying (mean=3.94), and family designating one family member as contact person for the rest of the family (mean=3.89).

Conclusion: As the number of deaths is increasing in critical care units, the needs to understand how the EOLC is provided in these units. Identifying obstacles and supportive behaviours will assist the stakeholders and policymakers to set the action plans for improving the quality of EOLC.

Authors: Loai Abu Sharour, Maha Subih, Omar Salameh, Mohammad Alrshoud