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

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

Abstract

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).

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

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

Abstract

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.

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Profile of children with rabies dog bites: Manado experience, Indonesia

Authors: Suryadi Nicolaas Napoleon Tatura, Elizabeth Clarissa Wowor, Priscilla Cantia Tatura-Kalensang, Meilany Duri, Tonny Homenta Rampengan

Abstract

Background: Rabies is an infectious viral disease that is almost always fatal following the onset of clinical signs. Forty percent of all human rabies occur in children <14-year-old. In up to 99% of rabies virus is transmitted by dogs.

Objective: To determine the mortality risk factor of children with rabies dog bites in Prof. Dr. RD Kandou Hospital, Manado, from 2012-2016.

Methods: We performed a retrospective cohort study of all pediatric patients with rabies dog bites. Rabies was diagnosed via detection of nucleoprotein from dogs brain using fluorescent antibody test (FAT). We used chi-square test and calculated odd ratio using software SPSS 23.0 to determine the mortality risk factor of patients with rabies dog bites, considering p value <0.05 as significant.

Results: During the study period, 38 children came with rabies dog bites (71.1% were boys). Incubation period range from 1 week to 4 years. Most common bites location was hand. Symptoms associated with rabies mortality were hydrophobia (OR 143, 95% CI 11.78-1735.96, p=0.0001), photophobia (OR 19.6, 95% CI 2.04-181.93, p=0.002), and hypersalivation (100% mortality, p=0.0001). Post-exposure vaccination associated with mortality of patients (OR 0.003, 95% CI 0.000-0.056, p=0.0001).

Conclusion: Hypersalivation, hydrophobia, and photophobia are major risk factors of rabies dog bites mortality. Post-exposure vaccination is important to prevent rabies infection after a high-risk bite.

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Multivessel spontaneous coronary arterial dissection. Usefulness of angio-CT during follow-up

Authors: JF Garrido Peñalver, JH de Gea García, R. Jara Rubio, E. Pinar Bermúdez, JI Pascual de la Parte, S. Sánchez Cámara

Abstract

Spontaneous coronary artery dissection (SCAD) is an uncommon but important cause of myocardial ischemia associated with a high mortality rate. Its aetiology, incidence and pathogenesis are still unknown. It is characterized by the presence of a hematoma and/or the separation of the different layers in the arterial wall, causing vessel lumen stenosis. The clinical manifestation depends on the extent and limitation of the blood flow caused by the dissection, and it varies from an asymptomatic presentation to acute myocardial infarction (50-75%), sudden cardiac death (0.5%) or heart failure.

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Unusual presentation of tension pneumoperitoneum during endoscopic submucosal dissection of early gastric tumor

Authors: Phui Sze Au Yong, Gek Kim Sharon Ong

Tension pneumoperitoneum is a well-known but rare complication of upper gastrointestinal endoscopy. It is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure resulting in hemodynamic or ventilatory compromise. The presentation varies from intense abdominal pain and tenderness to imminent collapse.

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Surgical emphysema complicating inferior alveolar nerve cryoablation

Authors: Ravi Mistry, Brigitte Hollander, Derek Goodison, Ross Freebairn

We present a case of widespread surgical emphysema following cryoablation of the right inferior alveolar nerve in the setting of trigeminal neuralgia refractory to carbamazepine pharmacotherapy.

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Electrical cardiometry for non-invasive cardiac output monitoring in children with dengue hemorrhagic fever and shock in comparison between referral and non-referral

Authors: Ira Dharmawati, Andri Kurnia Wahyudhi, Intani Dewi Syahti Fauzi, Arina Setyaningtyas, Dwi Putri Lestari, Neurinda Permata Kusumastuti, Abdul Latief Azis

Abstract

Objective: Shock in dengue hemorrhagic fever (DHF) is mostly caused by plasma leakage. Hemodynamic monitoring is essential for improving the quality of management and the outcome. We sought to find the hemodynamic profile of dengue hemorrhagic fever children with shock.

Design: a cohort prospective study.

Setting: Pediatric Intensive Care Unit (PICU) at tertiary general hospital in Surabaya, Indonesia.

Patients and participants: Children <18-year-old admitted to the PICU with diagnosis DHF with shock.

Intervention: All patients underwent measurement of hemodynamic profile with electrical cardiometry ICON OsypkaTM after the first fluid resuscitation.

Measurements and results: There were 37 patients with DHF grade 3. All patients had normal blood pressure on first examination, with the mean of systolic and diastolic blood pressure were 82.5±9.21 mmHg and 51.8±16.32 mmHg, respectively. They had low stroke volume (66.7%), high heart rate (60.6%), low cardiac output (49%), and high systemic vascular resistance (55%). Mean resuscitation fluid volume was 35.30±31.99 ml/kg, where referral patient had significantly higher resuscitation fluid volume (49.45±39.46 ml/kg) than non-referral (19.75±0.60 ml/kg), p=0.002. Thoracic fluid content were significantly higher in referral (75%) than those in non-referral patients (16.7%), p=0.001.

Conclusion: After first fluid resuscitation, children with DHF grade 3 obtained normal blood pressure but still in hypovolemic state. Referral patients had higher fluid volume resuscitation and thoracic fluid content than those in non-referral.

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The effectiveness of a short training course for emergency medicine residents to confirm tracheal tube placement by ultrasound

Authors: Mohammad Afzalimoghaddam, Kamal Basiri, Seyedhossein Seyedhosseini-Dvarani, Farideh Bagheri, Ehsan Karimialavijeh

Abstract

Objective: The present study aimed to evaluate the performance of tracheal ultrasound by novice emergency medicine residents after participating in a short training course.

Methods: This was an observational prospective study conducted between July 2016 and September 2017 at three university-affiliated emergency departments in Tehran, Iran. Adult patients (over 18 years of age) who needed emergency intubation were included. Investigators were emergency medicine residents who did not have prior experience in tracheal ultrasound. Training course consisted of 40 minutes of theoretical education and three days of hands-on training. Immediately after intubation by treating physicians, two investigators evaluated the placement of the tracheal tube simultaneously. One investigator used tracheal ultrasound and the second investigator used quantitative waveform capnography. The registrant was a nurse who was asked to record the results of each investigator in the following format: 1. Correct tracheal intubation, 2. Esophageal intubation, and 3. Time spent to complete the evaluation. Finally, the ultrasound results were compared with those of capnography.

Results: Ninety patients were included in the study. Based on the capnography results, there were three (3.3%) esophageal intubations and 87 (96.6%) tracheal intubations.  Investigators reported the same results by tracheal ultrasound. The mean±SD time spent to complete the evaluation was 32±10 seconds for capnography and 48±15 seconds for tracheal ultrasound (p value of 0.0001).Conclusion: Emergency medicine residents with basic knowledge of ultrasound can learn tracheal ultrasound techniques through a short training course.

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Fatal neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae

Authors: U Wen Yeap

Abstract

Klebsiella pneumoniae is a gram-negative rod enterobacteria that is notorious for its role as carrier of extended spectrum beta-lactamase (ESBL) and its carbapenem resistant Enterobacteriaceae (CRE) species. However, hypermucoviscous Klebsiella pneumoniae is distinctly different from ESBL and CRE. We report a case of neck necrotizing fasciitis caused by hypermucoviscous Klebsiella pneumoniae in a 56-year-old male who presented to our emergency department (ED) with a swollen neck. His condition deteriorated rapidly requiring emergency intubation to secure his airway. Despite aggressive resuscitation and treatment with broad spectrum antibiotics and cytokine adsorption therapy, the patient succumbed to his disease. This report describes the clinical characteristics of hypermucoviscous Klebsiella pneumoniae and emphasizes the importance of early detection and subsequent aggressive source control interventions in necrotizing fascitiis caused by this particular bacteria.

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Delirium in critically ill patients: incidence, risk factors and outcomes

Authors: Lavitha Vyveganathan, Azarinah Izaham, Wan Rahiza Wan Mat, Shereen Tang Suet Peng, Raha Abdul Rahman, Norsidah Abdul Manap

Abstract

Objective: To determine the incidence, and evaluate the risk factors and outcomes of delirium in general Intensive Care Unit (ICU).

Design: Prospective cross-sectional observational study.

Setting: Teaching hospital in Kuala Lumpur, Malaysia.

Patients and participants: Patients ages of 18 and above admitted for more than 24 hours in general ICU were recruited into the study.

Measurements and results:The demographic data, predisposing and precipitating factors, and environmental factors were collected. Confusional Assessment Method (CAM-ICU) was done daily to assess delirium, when the patient had a sedation score of above Richmond Agitation and Sedation Scale (RASS) -3. Patients were followed up till discharged from ICU. Length of mechanical ventilation and length of ICU stay were recorded.

A total of 139 patients were recruited with overall incidence of delirium was 42%. Among patients who had delirium, 68% were of hypoactive delirium, 25% of mixed delirium and 7% were hyperactive delirium. The significant predisposing risk factors for developing delirium were age, higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, visual or hearing impairment, smoking, renal impairment, diabetes, and hypertension. The factors detected precipitating delirium were sepsis, use of vasopressors, renal replacement therapies, and acute respiratory distress syndrome (ARDS). The presence of catheters, higher Sequential Organ Failure Assessment (SOFA) scores, and abnormal urea and bilirubin levels further significantly increased risk of delirium. Environmental conditions increasing the risk of delirium included absence of daylight exposure and visible clocks, and use of physical restraints. As a result of delirium, patients had longer length of mechanical ventilation and ICU stay.Conclusions: Recognizing predisposing factors and optimizing the modifiable risk factors will improve the length of mechanical ventilation and ICU stay.

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