Characteristics of the obstetric patients admitted to the Intensive Care Unit of Sanglah General Hospital in 2013-2016

Abstract

Background: High risk pregnancy and complication during pregnancy or labor may need multidisciplinary management in the Intensive Care Unit (ICU). This study shows the characteristics of obstetric patients who were admitted to the ICU of Sanglah General Hospital Denpasar, Bali, Indonesia in 2013 to 2016.

Objective: Our study was performed to provide database in Sanglah General Hospital regarding to the intensive care management of obstetric patients in the ICU of Sanglah General Hospital. This data may be beneficial to provide better management in the ICU, and also to reduce maternal mortality and morbidity.

Design: This was a descriptive study using the secondary data from the medical records of obstetric patients who were admitted to the ICU of Sanglah General Hospital in 2013 to 2016.

Setting: This study was performed in the ICU of Sanglah General Hospital, Denpasar, Bali, Indonesia.

Patients and participants: All obstetric patients who were admitted or transferred to ICU of Sanglah General Hospital in August 1, 2013 to August 31, 2016. There were 245 obstetric patients transferred to ICU of Sanglah General Hospital.

Result: Over the 3 years study period, there were 245 obstetric patients who were admitted to the ICU out of the total of 3089 deliveries during that period. Based on the gestational age during admission, there were 7.7% cases below 28 weeks (n=19), 36.3% were between 28-36 weeks gestational age (n=89), and 55.9% cases were 37 weeks and above (n=137). The indication of the admission can be categorized into the obstetrics indication, which were 75.1% out of 245 cases (n=184) and the non-obstetric indication such as the medical problem underlying during the pregnancy, which were about 24.9% out of 245 cases (n=61). The major indication of obstetric problem was the hypertensive disease in pregnancy, while the major indication of nonobstetric reason was the heart disease. The maternal mortality rate in the ICU during this study was 10.2% out of the 245 cases who were admitted to the ICU.

Conclusion: As the major tertiary referral hospital in Bali, Sanglah General Hospital were having high number of complicated pregnancy cases. The characteristics of the obstetric patients who were admitted to the ICU can be used to plan better management and appropriate care, especially in the ICU, in order to reduce the maternal mortality rate.


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Prevalence and association of cost and hospital malnutrition in Pediatric Intensive Care Unit Sanglah Hospital during 2015

Abstract

Background: Early nutritional screening and adequate enteral nutrition for critically ill patients, started 24 hours after admission in pediatric intensive care unit (PICU) are accepted to improve health outcomes. Malnutrition prior to admission worsens the prognosis of severely ill children and it will lead to a higher mortality, a longer length of stay, and a higher health cost.

Objective: The main outcome was to investigate the prevalence of hospital malnutrition on admission, discharge, and in-hospital in PICU Sanglah Hospital, Bali during 2015. The secondary outcome was to investigate the association of cost and hospital malnutrition.

Methods: A retrospective study was conducted in PICU Sanglah Hospital, Bali, from January to December 2015.

Patients and participants: Children aged 1 month to 12 years with complete medical records. We assessed the prevalence of hospital malnutrition using WHO Anthro software or WHO AnthroPlus software.

Results: From January to December 2015, there were 477 patients admitted to the PICU and 456 were enrolled in this study. Malnutrition was observed in 72 patients (15.8%) during PICU admission, 56 (17.2%) during discharged, and only 13 (2.9%) suffered from malnutrition during hospitalization. Multivariate analysis showed that malignancy was the only factor associated with in-hospital malnutrition. Malnutrition during admission and discharge were not associated with an increase in the length of hospital stay. But, in-hospital malnutrition was associated with longer length of stay (3.2 vs 14.0 days, p<0.001), and was associated with additional cost of Rp 5,500,000.

Conclusion: Malnutrition was observed in 72 patients during PICU admission, 56 during discharged and only 13 during hospitalization. Hospital malnutrition was associated with additional cost of Rp 5,500,000.


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Prognostic value of serum cholinesterase activity in the septic shock due to bacterial infections

Abstract
Context: Kinetics of SChE activity analyses, in our knowledge, was not previously studied in the prediction of prognosis of patients with septic shock.
Objective: We aimed to analyse kinetics of SChE activity in 4 patients with septic shock.
Materials and methods: Prospective study.
Results: The kinetics analyses of SChE activity showed that SChE activity was correlated with the prognosis (decrease in deads and increase in survivors).
Discussion and conclusion: The kinetics of SChE activity can be used as a biomarker to
predict the prognosis of patients with septic shock.


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The association between delta shock index and mortality in children with shock

Abstract
Background: Shock remains one leading cause of morbidity and mortality in hospitalized children. Delta shock index is a simple tool to assess and evaluate shock.
Objective: To investigate whether delta shock index might be related to mortality in children with shock.
Methods: Prospective cohort study.
Setting: Emergency Room (ER) and Pediatric Intensive Care Unit (PICU) of Sanglah University Hospital, Bali from March 2015 to March 2016.
Patients and participants: Children aged 1- month to 12-year-old that were diagnosed with shock during admission or during hospitalization. Subjects were divided into delta shock index (DSI)≤0 group and DSI>0.
Results: From March 2015 to March 2016 a total of 80 subjects were recruited. There were 40 cases with DSI≤0 and 40 cases with DSI>0. Mortality was found in 28 (70%) patients with DSI≤0 group. Chi-square analysis showed significant association between DSI and mortality (RR 1.9, 95%CI:1.2-2.9; p=0.004). Survival analysis showed median time survival was 5 days for the group with DSI≤0 and 7 days for the group with DSI>0 (log-rank 0.03). Cox regression analysis showed that DSI≤0 (RR 1.895, 95%CI:0.989-3.623; p=0.037) and age (RR 0.988, 95%CI:0.979-0.997; p=0.015) were risk factors for mortality in children with shock.
Conclusion: DSI≤0 was associated with mortality in children with shock.


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A randomized controlled trial: Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution

Abstract
Background: Hyponatremia is a condition that may cause dangerous clinical manifestations. Diarrhea with dehydration is one of the most common causes for hyponatremia. Intravenous hypotonic fluid is used for children with moderate dehydration and isotonic Ringer lactate is used for severe dehydration in several therapy guidelines for diarrhea.
Aims: To investigate the difference in changes of serum sodium levels between rehydration therapy with standard hypotonic solution and balanced solution for children with diarrhea and dehydration.
Design: Randomized controlled clinical trial.
Setting: Emergency unit in Dr. Soetomo General Hospital, Surabaya, Indonesia.
Patients: Forty children aged between 3 months to 12 years old who were diagnosed with diarrhea with moderate dehydration based on Haroen Noerasid’s clinical criteria. Patients were randomly assigned into two groups: standard hypotonic solution therapy group (n=21) and balanced solution therapy group (n=19).
Interventions: Children in the standard therapy group received standard hypotonic solution (Na+ 50 mmol/L), while the other group received balanced solution (Na+ 145 mmol/L) as the main fluid during rehydration therapy.
Results: The mean initial serum sodium levels in the standard hypotonic solution and balanced solution group were 141 mmol/L and 141.4 mmol/L, respectively. The difference was found to be not statistically significant. There was a statistically significant difference between the post rehydration mean serum sodium levels of the standard hypotonic (138.3 mmol/L) and balanced solution group (141.7 mmol/L). The mean reduction of serum sodium levels was 2.48 mmol/L in the standard hypotonic solution group and there was a mean increase of 0.37 mmol/L in the balanced solution group. We found clinically a not significant difference of symptoms of hyponatremia in this study. There was no seizure, neurological inpairment in both treatment groups before and after rehydration.
Conclusions: There were difference changes in serum sodium levels post rehydration therapy by using two different solutions. Balanced solution was more stable and a safer choice to protects against hyponatremia.

A randomized controlled trial- Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution


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Prediction of colloid osmotic pressure from albumin and/or hemodynamics in pigs undergoing hemorrhagic shock

Abstract
Background and purpose: Colloid osmotic pressure (COP) is strongly affected during by hemorrhagic shock (HS) and imbalances may result in pulmonary and systematic oedema. Measurement of COP is therefore crucial in order to monitor changes and to react to critical levels. The aims of this study were to examine the time-course effects on COP and albumin in pigs undergoing controlled HS, and to investigate whether albumin and/or hemodynamic parameters are relevant predictors of COP during HS.
Methods: 18 pigs randomly assigned in a blinded manner to one of three groups. Group 1: sham (n=4); group 2: hemorrhage control (n=7) and group 3: hemorrhage + adenosine, lidocaine and Mg2+/adenosine, lidocaine (ALM/AL) (n=7). COP was measured using a commercially available oncometer.
Results: Group 2 experienced the greatest change in absolute and relative COP-values during the experiment, while group 1, as expected, experienced the smallest change. Strong correlations were seen between COP and albumin for group 2 (0.84, p<0.001) and for group 3 (0.82, p<0.001), whereas moderate to negligible correlations were seen between COP and the hemodynamic parameters. Conclusion: Pigs subjected to HS compensated unexpectedly well compared to pigs not exposed to HS (sham). It is possible to predict COP from albumin, which may be clinically relevant in situations where an oncometer is not accessible. Further studies are needed if these findings are to be transferred to humans.


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Antimicrobial resistance patterns of Staphylococcus aureus in the intensive care unit at a tertiary hospital

Abstract
Purpose: The objective of the present study is to determine the pattern of antimicrobial resistance of Staphylococcus aureus (S. aureus) in the Intensive Care Unit at a tertiary hospital in Mexico.
Methods: 1,511 cultures in general surgery, internal medicine, neurosurgery and the ICU were analyzed, the sample pool was limited to ICU patients and out of those, only samples positive for S. aureus were included, meticillin resistance was confirmed.
Results: Of a total of 1,511 samples, 206 (13.63%) were culture positive for S. aureus. In the ICU, antimicrobial resistance to beta-lactams (penicillin, ampicillin, cephalothin, cefotaxime, cefazolin, amoxicillin/Ac. clavulanate and imipenem) averaged 73.52%; for clindamycin was 65.12%; ciprofloxacin 59.09%, erythromycin 65.31% and for vancomycin was 6.52%.
Conclusions: The present study showed a high incidence of MRSA in an Intensive Care Unit at a tertiary hospital.

Antimicrobial resistance patterns of Staphylococcus aureus in the intensive care unit at a tertiary hospital


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Superior cava vein saturation and cardiac lactate as cardiac output predictor after cardio-pulmonary bypass on children

Abstract
Objective: to evaluate cardiac heart lactate, superior cava vein saturation and microcirculation dysfunction as cardiac output predictors after surgery on patients with Tetralogy of Fallot (TF) through measuring serum level of sTNFR-1 and IL-6.
Design: cohort study
Setting: Cipto Mangunkusumo Hospital
Patient and participants: Subjects were children aged 1 to 6 years that underwent corrective surgery. Subjects who met the inclusion criteria were divided into 2 groups after ischemiareperfusion injury (post surgery). The first group was subjects with high cardiac lactate and the second group was subjects with low cardiac lactate.
Measurements and results: Subjects were observed for 24 hours; during surgery, 6 and 24 hours after aortic clamp removed. During July 2012 - December 2013, there were 52 patients who became subjects. There were proportion differences between cardiac lactate and cardiac output change after cardiac surgery. Increase of cardiac lactate has a correlation with increasing levels of sTNFR-1 and IL-6 and decreasing index of Tc, ScvO2 and cardiac output. There were correlations among low index of ScvO2, high index of cardiac lactate and decrease of cardiac output. High sTNFR-1 and IL-6 were correlated to low cardiac output. Cardiac lactate, ScvO2 and MAP can be used as predictors of cardiac output change in patients with cardio-pulmonary bypass. sTNFR-1 and IL-6 levels were correlated with cardiac output changes after cardiac surgery.
Conclusion: Cardiac lactate and ScvO2 are valuable in measuring cardiac output changes on patient with cardio-pulmonary bypass.

Superior cava vein saturation and cardiac lactate as cardiac output predictor after cardio-pulmonary bypass on children


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Association of fluid overload with mortality in pediatric intensive care unit

Abstract
Objective: To determine association of fluid overload with mortality in critically ill patients in Pediatric Intensive Care Unit.
Design: This was a case-control study.
Settings: Pediatric Intensive Care Unit of Sanglah Hospital Denpasar, Bali in January 2013 to December 2014.
Patients and participants: Samples were patients who had completed treatment in Pediatric Intensive Care Unit of Sanglah Hospital Denpasar. Data was taken from medical records by simple random sampling technique both in the case and control groups. The cases were nonsurvivors and controls were survivors.
Intervention: Observation made on fluid overload, defined as the fluid accumulation more than 10%.
Results: Total of 120 children were examined in this study, which consisted of 60 samples for both case and control groups. The mean percentage of fluid accumulation was significantly higher in the case group (12.9±7.9%) compared to control (-1.4±8.2%), with mean difference 9.4% (95% CI:5.4-13.3; p<0.001). Fluid overload was associated with mortality (OR 11.5; 95% CI:3.7-35.6; p<0.001). Conclusions: Fluid overload is associated to and a risk factor for mortality in critically ill patients in pediatric intensive care unit. Fluid accumulation is higher in the non-survivors than survivors. Association of fluid overload with mortality in pediatric intensive care unit


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Procalcitonin levels as predictors of neurological outcome in patients with cardiac arrest treated with mild therapeutic hypothermia: a retrospective study

Abstract
Background/objective: Procalcitonin (PCT) is a biomarker widely used to identify bacterial infections, diagnostic tool for sepsis, monitor response to antibacterial therapy, and to assess general inflammatory response. Our goal was to assess the relationship between PCT levels and neurological outcome in patients who suffered cardiac arrest (CA), and underwent mild therapeutic hypothermia (TH) at 32 °C for a period of 24 hours.
Methods: 55 patients with CA who underwent mild TH were enrolled. Three PCT measurements were obtained (PCT-1 prior to TH, PCT-2 during TH and PCT-3 after TH). Neurological outcome was evaluated with the Cerebral Performance Category (CPC) score. Descriptive statistics and analysis of variance (t-test and ANOVA) were used.
Results: From our cohort, 58.6% had a CPC≥3, 29.3% CPC 1 and 6.9% CPC 2. Mean PCT levels for each group were: PCT CPC 1 2.43 (+3.940 SD), PCT CPC 2 5.49 (+1.516 SD), and PCT CPC>3 4.077 (+8.805 SD). ANOVA between PCT-1 and CPC scores was F=0.354 (p=0.697), PCT-2 and CPC scores F=0.71 (p=0.501), and PCT-3 and CPC scores F=0.710 (p=0.496).
Conclusion: Our small sample size led to a significant difference of distribution. Further prospective studies with bigger samples are needed in order to obtain better results when assessing the significance of PCT levels as predictors of neurological outcome after CA and TH.

Procalcitonin levels as predictors of neurological outcome in patients with cardiac arrest treated with mild therapeutic hypothermia- a retrospective study


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Incidence of circulatory shock after spontaneous intracerebral hemorrhage and impact on case-fatality: a multi-center cohort study

Abstract
Objective: The epidemiology of circulatory shock after spontaneous intracerebral hemorrhage (ICH) is unknown. We sought to determine its incidence, risk factors, and effect on case-fatality.
Design: Retrospective multi-center cohort study.
Setting: 83 ICUs in the United States from 2003-2008.
Patients: Subjects with ICH >17 years of age admitted to an ICU. Shock was defined as sustained systolic blood pressure <90 mmHg for ≥1 hour despite vasopressors. Interventions: None. Measurements and results: A total of 4,192 ICH patients. Median age was 67 yrs (IQR 54-77), 2221 (53%) were male, and 3030 (75%) were white. Median APACHE-II score was 15 (interquartile-range [IQR] 11-21) and Glasgow Coma Scale (GCS) was 11 (IQR 6-14). Incidence of shock after ICH was 5% (212/4192). Case-fatality was 72% among shock vs. 30% without shock (p<0.0001). In multi-variable analysis the following were associated with increased case-fatality: age (OR 1.01, 95%CI:1.01-1.02), DNR status (OR 1.8, 95%CI:1.3-2.6), GCS<8 (OR 11.4, 95%CI:8.4-15.4), GCS 8-12 (OR 2.1, 95%CI:1.5-2.9), mechanical ventilation (OR 2.0, 95%CI:1.6-2.5), organ dysfunction (OR 1.7, 95%CI:1.4-2.0), spontaneous hypothermia (OR 7.3, 95%CI:2.8-19.3), APACHE ≥15 (OR 2.9, 95%CI:2.2-3.7), and shock (OR 1.9, 95%CI:1.2-3.0). EVD placement was associated with survival (OR 0.8, 95%CI:0.6-0.9). Conclusion: Circulatory shock after ICH is rare and associated with increased case-fatality. Incidence of circulatory shock after spontaneous intracerebral hemorrhage and impact on case-fatality- a multi-center cohort study


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Hyperoxia is associated with higher case-fatality in ventilated patients with intra-cerebral hemorrhage

Abstract
Objectives: To test the hypothesis that hyperoxia was associated with higher in-hospital case-fatality in ventilated patients with ICH admitted to the Intensive Care Unit (ICU).
Methods: Admissions of ventilated ICH patients within 24 hours of admission to the ICU at 77 United States hospitals between 2003-2008. Patients were divided into three exposure groups: hyperoxia (PaO2≥300 mmHg), hypoxia (PaO2<60 mmHg or PaO2/FiO2 ratio ≤300), and normoxia, not defined as hyperoxia or hypoxia. The primary outcome was in-hospital case-fatality. Results: 1,388 ventilated ICH patients. Mean age 63 years (SD 15), 47% (653/1388) female, and median GCS 5 (IQR 3-8). The overall case-fatality was 59% (812/1388). Upon admission to the ICU, 36% (492/1388) were normoxic, 47% (641/1388) were hypoxic, and 17% (238/1388) were hyperoxic on ABGt1. ABGt2 was accomplished in 780 patients, of whom 46% (352/780) were normoxic, 45% (352/780) were hypoxic, and 9% (67/780) were hyperoxic. Of the initially admitted hyperoxic patients, 15% (21/138) remained hyperoxic and had a case-fatality of 82% (18/21) as compared to 49% (67/138) who became normoxic and had a case-fatality of 46% (32/67) (crude OR 6.6, 95%CI:1.8-25, χ2=9.4, p=0.002). In a multivariable analysis controlling for other predictors of poor outcome and hospital specific characteristics, and a propensity-score, failure to correct hyperoxia was associated with higher case-fatality (adjusted OR 2.5, 95%CI:1.1-6.1, p=0.04). Conclusion: In ventilated ICH patients, failure to normalize hyperoxia was associated with higher case-fatality. These data underscore the need for studies of controlled re-oxygenation in ventilated ICH patients. Hyperoxia is associated with higher case-fatality in ventilated patients with intra-cerebral hemorrhage


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Electric velocimetry and transthoracic echocardiography for non-invasive cardiac output monitoring in children after cardiac surgery

Abstract
Objective: Assessment of cardiac output (CO) is essential in the management of children after cardiac surgery. Electric velocimetry (EV) is a newly developed monitoring method for CO and stroke volume (SV). However, applicability in a pediatric population, particularly after cardiac surgery, remains unclear. We sought to assess agreement of CO measured by EV and transthoracic Doppler echocardiography (TTE).
Design: Prospective observational study.
Setting: A cardiac intensive care unit (CICU) at a tertiary children’s hospital in Shizuoka, Japan.
Patients and participants: Children <18-year-old admitted to the CICU after cardiac surgery. Intervention: All patients underwent measurement of SV and CO using EV and TTE between 1 to 3 days after surgery. Measurements and results: Thirty patients were analyzed. We collected data on patient demographics, body surface area, vital signs, SV, CO, laboratory examination, drugs used, and type or surgery. There were significant correlations between EV and TTE in SV and CO values (r=0.909, p<0.001 and r=0.831, p<0.001, respectively). Bland-Altman analysis showed a good agreement between EV and TTE in SV and CO values (bias 1.33 mL, 0.08 L/min, and 0.02 L/min/m2, respectively, and limits of agreement -8.59 to 9.93 mL and -0.97 to 1.05 L/min, respectively). Mean percentage error for SV and CO values between EV and TTE were 13.76% and 13.19%, respectively. Conclusions: There is good correlation and clinical agreement between EV and TTE in measuring SV and CO. Electric velocimetry can be used in the hemodynamic monitoring of children after cardiac surgery. Electric velocimetry and transthoracic echocardiography for non-invasive cardiac output monitoring in children after cardiac surgery


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The impact of illness severity evolution measured with LOD, SOFA, APACHE II and SAPS II scores on the development of ICU acquired infections

Abstract
Several studies were intended to evaluate ICU risk factors, but only few integrated the impact of illness severity variation in their study.
The aim of the present study is to explore the illness severity variation for patients having contracted an ICU-acquired infection and to check if this variation correlates to the nosocomial episode. The study is mono-centric, retrospective and non interventional. It is a case control type with matching approach 1 case vs. 1 control. It is based on a total of 250 patients, at least of 16-year-old, who spent a minimum of 72 hours in the ICU of Timone University Hospital.
The severity of the illness was measured according to the following scores: Logistic Organ Dysfunction (LOD), Simplified Acute Physiology Score (SAPS), Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE).
These scores were calculated retrospectively each day, from the day of admission in ICU to the day of discharge or death, except for APACHE score, which is interesting only for the first 24h of admission. The ability of the models for predicting ICU mortality was determined by examining their discrimination. Forty-six patients developed one or more nosocomial episodes, and 65 died. The matching of cases was successful for 71.73% of them. All SOFA scores values are higher in the case's group: IS (6.652±2.946 cases vs. 5.795±2.494 controls), H48 (6.652±2.767 cases vs. 5.077±2.082 controls), H72 (6.957±2.944 cases vs. 4.538±2.258 controls).
It is quite similar for the LOD score IS (6.087±2.889 cases vs. 5.821±2.72 controls), H48 (5.870±2.864 cases vs. 5.154±1.94 controls), H72 (5.761±2.677 cases vs. 5.256±2.074 controls). As far as APACHE II score is concerned, it counts: 20.478±7.938 cases vs. 24.23±7.938 controls. Among the four documented scores, only SOFA H48 has foreseen a nosocomial risk.


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The obesity supine sudden death syndrome in the perioperative patient

Abstract
The obesity supine death syndrome (OSDS) is a disease characterized by sudden cardiac arrest in the morbidly obese patient. We present the case of a 50-year-old man who in the immediate postoperative period developed hypoxemia, bradycardia and irreversible cardiac arrest. After a careful review of the perioperative events and a literature review, we attributed his demise to the OSDS. This syndrome is characterized by sudden desaturation following supine position in patients with a body mass index (BMI) in excess of 50 kg/m2. While the pathophysiology of OSDS is not fully understood, perioperative clinicians require an awareness of this condition to avoid this potential fatal outcome.
The Obesity supine sudden death syndrome in the perioperative patient


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