Sepsis-induced T-cell suppression in pediatric sepsis

Authors: Antonius Hocky Pudjiadi


Sepsis contributes to significant mortality and morbidity in children. Despite rigorous resuscitation effort, adequate antibiotics and advanced medical support, a significant proportion still face mortality due to multiple organ failure. Recent hypothesis suggests host’s immune response pathology in the form of compensatory anti-inflammatory response syndrome (CARS). This review aims to elucidate the pathophysiology of immune paralysis, both affecting innate and acquired immunity.

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Comparison of serum tumor necrosis factor, superoxide dismutase, and heat shock protein-70 levels during cardiopulmonary bypass and ischemia reperfusion injury after cardiopulmonary bypass in cardiac surgery

Authors: Teuku Aswin Husain, Setiawan P, Yan Efrata Sembiring, Budiono


Objective: This study aims to determine the comparison between tumor necrosis factor (TNF)-a, superoxide dismutase (SOD), and heat shock protein (HSP)-70 levels during cardiopulmonary bypass (CPB) and ischemia reperfusion injury after cardiopulmonary bypass.

Design: This study was an analytical observational study with a cross sectional design.

Setting: This study was conducted at Dr. Soetomo General Hospital Surabaya. The period of study was from April 2020 to September 2020.

Patients and participants: Population of study was all adult patients who underwent on pump cardiac surgery. Study samples were patients who were included in inclusion criterion. Patients’ characteristics were presented as frequency and percentage.

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Statistical test using the Wilcoxon signed-ranks test (two-tailed) was performed to determine comparison of TNF-a, SOD, and HSP-70 levels during CPB and after CPB. There were 30 subjects who underwent adult cardiac surgeries including coronary artery bypass graft (CABG), valve, and double procedures. According to statistical test, there was a significant increase of TNF-a, SOD, and HSP-70 levels during cardiopulmonary bypass compared to after cardiopulmonary bypass with p-value <0.05. Pearson correlation test was performed to determine the correlation between elevated levels of TNF-a, SOD, HSP-70 during CPB impact. There was significant correlation between TNF-a and SOD (p<0.05), and also between SOD and HSP-70 (p<0.05).

Conclusion: Our study showed that CPB impact significantly contributes to the increase of TNF-a, SOD, and HSP-70 levels compared to after CPB in patient undergoing on pump cardiac surgeries.

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Receptor-interacting protein kinase 3 has a good accuracy in predicting mortality of critically septic patients

Authors: Mayang Indah Lestari, R. Sedono, Zulkifli, IA Liberty


Objective: Sepsis-related uncontrolled systemic inflammation may trigger necroptosis, which is correlated with receptor-interacting protein kinase 3 (RIPK3) level. A high level of RIPK3 is associated with organ dysfunction and thus, mortality. This study aimed to analyze the ability of RIPK3 level to predict mortality in septic patients.

Design: This was a prospective cohort study.

Setting: This study was conducted in intensive care unit from February until August 2019.

Patients and participants: This study included patients aged 18 years or more who met the Sepsis-3 definition. Baseline demographic data were measured.

Interventions: Blood was collected to measure RIPK3 at sepsis recognition. RIPK3 level was measured using enzyme-linked immunosorbent assay using Bio-Rad (Bio-Rad Laboratories, California, US). Hour-1 bundle resuscitation was performed on all participants. Participants were observed for 28 days for mortality. Data were analyzed using STATA program software.

Measurement and results: A total of 59 subjects were analyzed. The cutoff point of RIPK3 level was 0.51 ng/ml with 92.5% sensitivity and 89.5% specificity in predicting mortality. RIPK3 level has an excellent performance with area under the receiver operating characteristic (ROC) curve (AUC) value of 0.925.

Conclusions: RIPK3 level can be considered a useful tool to recognize high risk mortality among critically septic patients.

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Clinical profile and outcomes in adults with status epilepticus – A prospective observational study

Authors: Aiswarya M. Nair, Priyadarshini Varadaraj, Sivaprakash Varadan, Vaasanthi Rajendran, Viswanathan Pandurangan, K. Madhavan, Anurag P.


Objectives: Status epilepticus (SE) is a common life-threatening medical emergency, and its neurological outcome requires prompt recognition and management. The present study aimed to determine the clinical profile and outcome of patients with status epilepticus.

Design: Prospective observational study.

Setting: The study was conducted in intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre from March 2018 to September 2019.

Patients and participants: Forty-six status epilepticus patients attending intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre were included and followed for 45 days.

Measurements and results: Baseline data on demographics, comorbidities, duration of each episode, number of episodes, treatment, brain imaging findings (computed tomography [CT] and magnetic resonance imaging [MRI]) and other comorbidities. The collected data was analyzed by analysis of variance (Anova) and independent t-test. P-value <0.05 was considered statistically significant. Out of 45 subjects included in the final analysis, 34 (75.6%) survived, and 11 (24.4%) had died during hospitalization. Mean±standard deviation of age was 43.1±1.02. Thirteen (71.1%) had diabetes mellitus as comorbidity. Twenty-four (53.3%) of them had >15 mins of seizure, 22 (48.9%) were in between 5 to 12 of Glasgow coma scale score. Among the study population, the probable etiology was head trauma 5 patients (11%), viral meningoencephalitis 7 patients (15.6%), acute cardiovascular system 9 patients (24.4%), and alcohol withdraw 14 patients (8.9%). Majority of them (18 patients [40%]) required third-line treatment, 33 patients (73.3%) required in hospital ventilator assistance, and 19 patients (42.2%) developed refractory status epilepticus (RSE). The duration of hospital stay was found to be significant for third-line treatment (21.9 days), mechanical ventilation (21.30 days), and RSE (23.8 days) with a p-value of 0.001.

Conclusion: The duration of hospital stay was significantly associated with the findings on brain MRI, the requirement of in-hospital ventilatory support, the treatment given, and the presence of RSE.

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Upper airway obstruction due to bilateral laryngeal polyp: A challenge of treatment in rural area

Authors: Hamsu Kadriyan, Elya Endriani, Fahrin Ramadhan Andiwijaya, Ida Lestari Harahap


A laryngeal polyp is a common benign lesion of phonotraumatic origins. However, a case of the laryngeal polyp with the upper airway obstruction is rare. The common symptoms include hoarseness or reduced vocal quality, and dyspnea could be present in severe cases. Depending on the anatomical location of the polyp, manipulation on the larynx could cause laryngospasm and life-threatening airway obstruction. In this case, the patient underwent a planned cesarean section under general anesthesia. However, her breathing rhythm did not return spontaneously after surgery and she was sent to the intensive care unit. Bilateral laryngeal polyps were discovered after the removal of an endotracheal tube. However, there was a delay in the removal of the polyps, where it was performed two months after the intensive care unit discharge. The histopathological results confirmed a diagnosis of bilateral angiomatous laryngeal polyps.

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Herpes simplex virus simultaneous encephalitis and liver failure in an immunocompetent adult: A case report

Authors: Tiago Isidoro Duarte, Filipe Damião, Joana Ferrão, Tânia Sequeira, Filipe Sousa Cardoso, Nuno Germano


Herpes simplex virus (HSV) are challenging etiologic agents with a wide range of clinical manifestations. We present a case of a 34-year-old immunocompetent male who was brought to the Emergency Department (ED) with fever and prostration. In the first approach, blood tests revealed an acute hepatitis without an identified etiology. Besides the use of N-acetylcysteine, he became worst and evolved to acute liver failure and coma. HSV deoxyribonucleic acid (DNA) was identified in the cerebrospinal fluid (CSF) and blood. Although acyclovir was started on day 3, he developed cardiovascular shock with multiple organ failure and died on the 7th day of hospitalization. A high index of suspicion is needed, and early diagnosis should be promoted between clinicians.

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Invasive mechanical ventilation during the first wave of COVID-19: Management and outcomes

Authors: Mafalda Aguiar Mourisco, Filipa Resende Brochado, Filipe Silva Machado, Diana Moreira Dias, Ricardo Pinho, Paulo Reis Rodrigues


Objective: To describe demographics, clinical, and respiratory mechanics (including ventilatory management details) of patients admitted to the Intensive Care Unit (ICU) with severe COVID-19 and to evaluate the effectiveness of gas exchange variables, ventilatory parameters, and ICU illness severity scores in predicting 28-day mortality.

Design: Single-center retrospective cohort study.

Setting: Portuguese medical-surgical ICU.

Patients: Adults sequentially admitted to the ICU, from March 18 to May 12, 2020, with critical COVID-19 requiring invasive mechanical ventilation (IMV) for over 48 hours.

Interventions: None, due to study design.

Measurements and results: Data regarding positioning, positive end-expiratory pressure (PEEP), driving pressure, static lung compliance, and lowest daily arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio throughout the first 5 days of ICU admission were collected from daily ventilatory assessment charts. The median ICU length of stay was 11.3 days and median IMV duration was 9.5 days. The 28-day mortality was 12.1%. When comparing non-survivors and survivors, significant differences were found regarding Simplified Acute Physiology Score (SAPS) II (48.5, IQR 14.0 vs. 32.0, IQR 11.0, p=0.004), PaO2/FiO2 ratio before endotracheal intubation (101.3, IQR 22.5 vs. 174.1, IQR 9.5, p=0.01) and throughout ICU stay. Over 90% of patients were submitted to prone positioning. Use of low PEEP levels and maintenance of low driving pressures in patients whose overall compliance was low as possible.

Conclusions: Significant differences were found regarding SAPS II and PaO2/FiO2 ratios between survivors and non-survivors, eliciting further investigation as potential mortality predictors. With the second wave of the pandemic taking shape, sharing previous experience is crucial to further coordinate efforts internationally.

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Restrictive fluid and fluid removal approach in diabetic ketoacidosis with septic AKI: A case report

Authors: Elvia AS, Mayang Indah Lestari, Yohannes WH George


Diabetic ketoacidosis is a life-threatening complication that requires a rapid restoration of intravascular volume usually with aggressive administration of intravenous fluid with 0.9% sodium chloride as recommended by the American Diabetes Association. We report a 50-year-old obese female patient with a history of diabetes mellitus (DM) since 20 years ago and routinely using insulin. She experienced dyspnea and presumably was caused by diabetic ketoacidosis. The patient was given fluid resuscitation with normal saline, but the dyspnea did not resolve and the work of breathing increased further, so the patient was intubated and admitted to the intensive care unit. Aggressive fluid resuscitation carries potential adverse effects such as hyperchloremic metabolic acidosis, interstitial multi-organ edema, and increased incidence of acute kidney injury. The first day of ICU treatment, positive cumulative fluid balance occurred and fluid removal was indicated. Fluid removal using diuretic or ultrafiltration is a part of the treatment of organ congestion and fluid overload after the initial phase of shock resuscitation to achieve negative fluid balance. This case showed that restricted fluid and fluid removal improve the patient outcome, especially in diabetic ketoacidosis and septic AKI patients.

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Outcomes in severe SARS-CoV-2 patients with liberal oxygenation and steroid therapy – a single centre experience

Authors: Priyadarshini Varadaraj, Sowmya Gopalan, Aiswarya M. Nair, Lakshmi Marappa, Vaasanthi Rajendran, Viswanathan Pandurangan, Sudha Madhavan, Rajkumar Mani, Emmanuel Bhaskar

Real-world reports on outcomes of SARS-CoV-2 infection using higher oxygenation targets along with steroid therapy are lacking. We conducted a retrospective study of patients requiring oxygen support following targets of oxygenation >95% along with steroid therapy. Group 1 with oxygenation through a nasal cannula or Hudson mask, Group 2 oxygenation with venturi system, and Group 3 with high flow nasal oxygen, 35-50 litres; non-invasive ventilation; mechanical ventilation delivering. One hundred and eighteen patients (Group 1 74 patients, Group 2 15 patients, and Group 3 29 patients) were studied. The mean age was 55.7 years and most were male (n=77). One hundred and fourteen received dexamethasone or methylprednisolone. Most (88.3%) had at least one pre-existing chronic medical illness. Overall mortality was 22.8% (n=27). Group 3 had the highest mortality (75.9%) followed by Group 2 (26.7%) and Group 1 (1.35%). Our observation raises the query if a higher target of oxygenation for non-mechanical ventilated patients coupled with steroid therapy is beneficial.

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What is low cardiac output syndrome? A report of two cases

Authors: Yuichi Baba, Toru Kubo, Yuri Ochi, Tatsuya Noguchi, Naohito Yamasaki, Hiroaki Kitaoka


Background: One of the diagnostic criteria of low cardiac output syndrome (LOS) is a cardiac index of less than 1.8 l/min/m2. However, recognition of this syndrome differs among intensivists as to whether or not LOS is synonymous with cardiogenic shock.

Case reports: Here, we present two cases of heart failure who were initially treated with diuretics and subsequently fell into a state of low cardiac output. We treated the patient with low blood pressure with inotropes and the patient with high blood pressure with a vasodilator according to their hemodynamics. We observed that cardiac power was the most significant hemodynamic change in response to these treatments. In this paper, we discuss the definition of LOS and show several criteria for determining LOS.

Conclusions: Broadly, there are several conditions of determining LOS. Even with those conditions, we should still be aware of the pathophysiology of each patient with heart failure. We propose that the definition of LOS should be a state of low cardiac output with corresponding symptoms, even if their blood pressure is high.

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