Early hydrocortisone, ascorbate and thiamine therapy for severe septic shock

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.


Authors: Micah T. Long, Mark A. Frommelt, Michael P. Ries, Melissa Murray, Fauzia Osman, Bryan M. Krause, Pierre Kory

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

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.


Authors: Hamzah, Arie Utariani, Bambang Pudjo Semedi, Yoppie Prim Avidar, Nanang Nurofik

Role of S100B, sTNFR-1, lactate, ScvO2, and SctO2 measured by NIRS as predictor of neurological deficit in pediatric congenital heart surgery

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.


Authors: M. Tatang Puspanjono, Sri Rezeki SH Hadinegoro, Bambang Sutrisna, Suhendro, Tjipta Bahtera, Amir S. Madjid, Siti Boedina Kresno, Dwi Putro Widodo, Rubiana Sukardi

Blood lactate levels during cardiopulmonary bypass as indicator of outcome in pediatric cardiac surgery

Abstract

Objectives: In pediatric cardiac surgery, high blood lactate levels during cardiopulmonary bypass (CPB) are associated with tissue hypoperfusion and contribute to postoperative complications. Studies indicate that blood lactate level is proportional to tissue oxygen debt. The objective of this study was to evaluate the change in blood lactate levels and perioperative morbidity and mortality.

Methods: We conducted a retrospective analysis of 81 pediatric patients who have undergone cardiac surgery with continuous monitoring of serial measurement of blood lactate in Integrated Cardiac Service Unit, Dr. Cipto Mangunkusumo Hospital, Jakarta. Arterial blood samples were taken before, during CPB, and on admission to the Intensive Care Unit (ICU) and every 6 hours afterward. Duration of CPB, hemodynamic parameters, inotrope dosage and perioperative outcome were documented.

Results: The largest increment in lactate level occurred during CPB and decreased on admission to the ICU. Patients who had complications exhibited higher lactate levels at all time points. Lactate levels were higher in the group with complications at the end of surgery (4.4 vs 2.7 mmol/l; p=0.000), immediately after ICU admission (2.9 vs 1.9 mmol/l; p=0.000), 6 hours (1.9 vs 1.4 mmol/l; p<0.003), and 12 hours after admission (4.6 vs 2.8 mmol/l; p=0.000). Increased lactate concentration was reliably associated with patient length of ICU stay, liver function parameter and anion gap. Logistic regression analysis revealed that peak blood lactate levels of 3.5 mmol/l or higher during CPB were strongly associated with postoperative mortality and morbidity.

Conclusions: Hyperlactatemia occurs during CPB may become an early indicator/predictive index for postoperative morbidity and mortality in pediatric patients. This study generates the hypothesis that strategies aimed to preserve oxygen delivery during CPB may reduce the occurrence of elevated lactate levels.


Authors: M. Tatang Puspanjono, Antonius H. Pudjiadi, Jusuf Rachmat, S. Harry Purwanto

Serum glial fibrillary acidic protein is a more specific biomarker than phosphorylated neurofilament heavy subunit, heart-fatty acidic protein, neuron specific enolase, and S100B protein for CT-positive mild-to-moderate traumatic brain injury

Abstract

Background: Several biomarkers show diagnostic value for traumatic brain injury (TBI), especially in patients with severe TBI. In the present study, we examined whether glial fibrillary acidic protein (GFAP), phosphorylated neurofilament heavy subunit (pNF-H), heart-type fatty acid binding protein (H-FABP), neuron-specific enolase (NSE), and S100B protein (S100B) measured on admission to an emergency department showed diagnostic value in patients with mild-to-moderate TBI.

Methods: A prospective study performed in our emergency department. After collecting informed consent, blood samples were obtained to measure GFAP, pNF-H, H-FABP, NSE, and S100B concentrations. All of the patients underwent head computed tomography (CT). The CT findings were considered positive if hemorrhagic brain injury was present. Receiver-operating characteristic (ROC) curve analysis was performed for each biomarker with positive head CT findings as the outcome variable.

Results: Fifty-seven patients were included (39% male). Their median age was 70 years and the median Glasgow coma scale score was 15. Twelve patients (21%) had positive head CT findings (CT-positive group). The area under the ROC curves for GFAP, pNF-H, H-FABP, NSE, and S100B were 0.845, 0.569, 0.518, 0.744, and 0.753, respectively, and were statistically significant for GFAP, NSE, and S100B (p<0.001, p=0.013, and p=0.010, respectively). The area under the ROC curve was greater for GFAP than those for the other biomarkers.

Conclusions: Our results suggest that serum GFAP measured shortly after emergency department admission shows greater diagnostic potential for head CT-positive TBI as compared with pNF-H, H-FABP, NSE, and S100B.


Authors: Tadashi Kaneko, Tadashi Era, Kohei Karino, Shu Yamada, Maki Kitada, Toshihiro Sakurai, Masahiro Harada, Fumihiko Kimura, Takeshi Takahashi, Shunji Kasaoka

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

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.


Authors: Trisulo Wasyanto, Savithri Indriani, Ahmad Yasa

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

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.


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

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

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.


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

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

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.


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

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

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

Abstract

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

Abstract

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

Abstract

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