Is hyperchloremia following sepsis resuscitation with 0.9% saline clinically important?

Authors: Elliot Long, Franz E. Babl, Fran Balamuth, Scott Weiss

The authors of the article titled “Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: a randomized, double-blind controlled trial”, published in Critical Care and Shock, should be congratulated for design and conduct of a randomized, double-blind clinical trial in severely unwell children with sepsis. The patient population included in the study was severely unwell: all patients enrolled went on to require inotropic therapy, and overall mortality was 24.6%. This stands in contrast to industrialized countries, where inotrope use and death from septic shock are significantly lower. The generalizability of findings between regions...

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Mortality in COVID-19 patients receiving systemic anticoagulant: A systematic review and meta-analysis

Authors: Patan Ahmad Setiabudi, Andry Gonius, Thoha Muhajir Albaar, Wella Karolina, Eliana Susilowati, Novi Kurnianingsih

Abstract

Background: Coronavirus disease 2019 (COVID-19)/Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a pandemic disease that quickly spreads throughout the world. There are no definitive therapeutic recommendations that give benefit results until recently. Recent studies suggest that coagulopathy is one of the complications of COVID-19 that increases the mortality rate regardless of the severity. This systematic review and meta-analysis aims to explore the association between systemic anticoagulant use and mortality in COVID-19 patients with various clinical conditions.

Methods: We performed a comprehensive search from several databases. The anticoagulant used in this study comprises of systemic anticoagulants such as low molecular weight heparin (LMWH) or others. The primary outcome was all-cause mortality related to anticoagulant use in COVID-19 patients. The meta-analysis was performed to see the significance of anticoagulants in decreasing the mortality rate of COVID-19 patients.

Results: 7064 patients were analyzed from 7 studies. The meta-analysis showed that systemic anticoagulant use was related with lower mortality rate (RR 0.70 [0.51, 0.97], p<0.03; I2: 87%, p<0.00001). The systematic review reported that 4 of 7 studies favor decreasing the mortality rate in COVID-19 patients administered with systemic anticoagulants.

Conclusion: Systemic use of anticoagulants was associated with a lower mortality rate in COVID-19 patients. Further studies are needed for better causation explanation. The implication of this study is to measure the mortality impact of systemic anticoagulant use in COVID-19 patients.

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Neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume as a predictor of sepsis mortality in children at Dr. Soetomo General Hospital

Authors: Frans M. Pasaribu, Arina Setyaningtyas, Mia Ratwita Andarsini

Abstract

Objective: The purpose of this study was to analyze the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) as a predictor for mortality in children with sepsis.

Design: This was a prospective cohort study.

Setting: In Pediatric Intensive Care Unit (PICU), Emergency Room, and pediatric ward at Dr. Soetomo General Hospital, Surabaya on March 1, 2020 to August 2020.

Patients and participants: A total of 80 children consisted of 40 septic and 40 non-septic patients were included.

Measurement and results: The leukocyte count in septic patients was not significantly higher than in non-septic patients with a p value>0.05. The number of neutrophils (12.99±7.35x103/mm3 versus 9.12±6.67x103/mm3) had a relevant and significantly higher increase in septic patients (p=0.014). The NLR value (8.99±6.73 versus 4.80±5.30; p=0.001) was higher in septic patients. The cut-off of NLR as a diagnostic marker for sepsis was 3.52 with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) of 82.50%, 47.50%, 61.11%, 73.08%, and 4.26 (p=0.004), respectively. The MLR, PLR, and MPV did not differ significantly between septic and non-septic patients. NLR values (11.61±7.39 versus 5.77±4.05; p=0.014) between survive and dead septic patients. The NLR cut-off 8.98 has sensitivity, specificity, PPV, NPV, and OR of 77.78%, 54.55%, 58.3%, 75%, and 4.20 (p=0.038), respectively, as a predictor for mortality. Patient with NLR more than 8.98 has a risk for mortality 4.20 times higher than those with a low or equal NLR value.

Conclusion: NLR can be used as a predictor of mortality in children with sepsis.

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The correlation between vasoactive-inotropic score with mortality and the use of mechanical ventilation in pediatric shock admitted to the PICU in Dr. Soetomo General Hospital, Surabaya

Authors: Iin Fatimah, Arina Setyaningtyas, Ira Dharmawati, Abdul Latief Azis, Neurinda Permata Kusumastuti, Dwi Putri Lestari

Abstract

Objective: To evaluate and to assess the correlation between the vasoactive-inotropic score (VIS) with mortality and the used of mechanical ventilation in pediatric shock.

Design: A retrospective cross-sectional study.

Setting: The study was conducted in the Pediatric Intensive Care Unit (PICU) at Dr. Soetomo General Hospital, Surabaya from November 1st, 2017 until April 30th, 2018.

Patients and participants: All children <18-year-old with shock who were admitted to the PICU.

Interventions: None.

Measurement and results: Eighty children with shock were admitted in PICU using minimal one vasoactive-inotropic treatment in the first 48 hours were included. Fifty-nine patients were eligible and met the inclusion criteria such as age <18-year-old, has one or more types of shock (hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock), and received at least one vasoactive-inotropic drug £48 hours. We used Chi-square and Fisher’s Exact test and Receiver Operating Characteristic (ROC) curve analysis. The children consisted of 31 males (52.5%) and 28 females (47.5%). The median age was 36 ranging from 2-216 months. Fifty-four used mechanical ventilation. The mean of VIS was 10±6 and the mortality rate was 47.5%. The cut-off value of the ROC curve of VIS in relation to mortality was 6 with sensitivity 82.1% and specificity 64.5%. We divided our subjects into two groups based on the cut-off value of 6 as High VIS (>6) and Low VIS (≤6). The High VIS group consisted of 34 subjects, in which 68% of them died and 59% of them needed mechanical ventilation. VIS had a correlation with mortality (r=-0.472, p<0.001).

Conclusion: VIS had a moderately correlation with mortality, but had no correlation with the used of mechanical ventilation. Nevertheless, VIS may be a better screening tool for pediatric shock in our setting.

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Effect of zinc supplementation in PELOD-2 score and zinc serum level in children with sepsis

Authors: Winny, Munar Lubis, Erna Mutiara

Abstract

Background: Sepsis in children still shows a high mortality rate. Nutritional factors are important in the treatment of sepsis. Zinc is one of the key elements that can limit mitochondrial dysfunction due to an imbalance between reactive oxygen species and antioxidants that occur in sepsis. We aim to determine the effect of Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score and zinc serum level before and after zinc supplementation in septic children.

Methods: This is an experimental study with one group pretest-posttest design in patients aged 1 month to 18 years with sepsis treated at the PICU H. Adam Malik General Hospital from March 2018-February 2019. Oral zinc supplementation was given for 5 days. The PELOD-2 score and zinc serum level measurement were performed by using inductively coupled plasma-mass spectrometry (ICP-MS) on the first and fifth days. Bivariate analysis was performed by paired T test.

Results: A total of 17 patients were analyzed. The paired T test showed significant difference in serum zinc levels before and after supplementation (p<0.001) even though the zinc levels were both still below normal values (28.7±11.7 µg/dl and 40.5±18.3 µg/dl, respectively). PELOD-2 score still showed increasing values with significant differences (p<0.001) before and after zinc supplementation (7.76±2.4 and 11.7±3.3, respectively).

Conclusion: This was the first report that evaluated effect of zinc supplementation on PELOD-2 score. Zinc supplementation did not decrease PELOD-2 score but could give significant improvement in zinc serum level.

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Lower target temperature management in patients with post-cardiac arrest syndrome could not show advantage, with or without resuscitation interval ≤30 minutes. Retrospective analysis of nationwide multicenter observational study in Japan

Authors: Kazuya Odawara, Tadashi Kaneko, Shunji Kasaoka

Abstract

Introduction: Target temperature management (TTM) is one of the effective therapies for patients with post-cardiac arrest syndrome (PCAS). A low target temperature is traditionally believed to be more effective, but this has not been confirmed in recent studies, even in any patient subgroup. Our previous study suggested the possible effectiveness of low TTM for patients with PCAS when the period from collapse to the return of spontaneous circulation (ROSC) is ≤30 minutes. Therefore, we tested this hypothesis in a nationwide Japanese registry.

Methods: This was a retrospective subanalysis based on a registry of patients who experienced out-of-hospital cardiac arrest (OHCA), which was established by the Japanese Association for Acute Medicine. Witnessed cases of adult OHCA were selected. Univariate and multivariate analyses were used to compare the neurological outcomes of patients treated with low (32-33 °C) or mild (34-36 °C) TTM or no temperature management. The analysis was performed in both the total patients and in patients in whom the interval from collapse to ROSC was ≤30 minutes.

Results: We analyzed 1763 cases of PCAS. There was no significant difference in the neurological outcomes of patients treated with low or mild TTM, with or without an interval from collapse to ROSC of 30 minutes. However, neurological outcomes of patients treated with low or mild TTM differed significantly from no temperature management, with or without an interval from collapse to ROSC of ≤30 minutes.

Conclusions: Even in the subgroup in which the interval from collapse to ROSC was ≤30 minutes, neurological outcomes in the low TTM group did not differ significantly from those in the mild TTM group.

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The validity of urinary neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker of acute kidney injury in pediatric patients with sepsis

Authors: Nugroho Setia Budi, Arie Utariani, Elizeus Hanindito, Bambang Pujo Semedi, Ninik Asmaningsih

Abstract

Background: Septic patients with acute kidney injury (AKI) are associated with increased morbidity and mortality compared to septic patients without AKI. These usually occur within 24 hours of admission into ICU. The measurement of serum creatinine is usually used to diagnose AKI. However, the concentrations do not change until a decline in kidney function has reached 50% or less within a few days. Many studies have shown urinary neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of AKI with different cut-off points.

Objective: This study aimed to determine the cut-off point of urinary NGAL in predicting the occurrence of AKI in pediatric septic patients within 48 to 72 hours after being admitted into ICU.

Methods: This was an observational analytic study with prospective longitudinal design, carried out on patients who met the inclusion and exclusion criteria at the resuscitation room in the Emergency Room (ER) at Dr. Soetomo Hospital Surabaya. The urine was taken at the 0th, 6th, 12th, and 24th hours for urinary NGAL examination. Every procedure taken on each patient was recorded and followed until the third day to determine factors correlated with AKI.

Result: Of the total 41 pediatric septic patients, 30 met the inclusion and exclusion criteria and about 56.7% had AKI. The urinary NGAL at 0th hour had significant value. A cut-off point of 1242 ng/ml was a better determinant of the incidence of AKI with a sensitivity of 76.5%, specificity of 61.5%, area under the curve (AUC) of 0.715, and relative risk of 2.2. Furthermore, the urinary NGAL at 0th hour was able to differentiate each level of AKI. Yet, the urine values of NGAL at 6th, 12th, and 24th hours were invalid as predictor of AKI.

Conclusion: Urinary NGAL at 0th hour is a valid predictor of occurrence of AKI grades 1, 2, and 3 in pediatric septic patients 48-72 hours after being admitted into the hospital.

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The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension

Authors: Zouheir Ibrahim Bitar, Ossama Sajeh Maadarani, Tamer Mohamed Zaalouk, Mohammed Jaber Mohsen, Ragab Desouky Elshabasy, Mahmoud Mostafa Elzoueiry

Abstract

Introduction: The World Society for the Abdominal Compartment Syndrome (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) £15 mmHg. The role of point-of-care ultrasound (POCUS) as a bedside modality in critical care patients, is not well studied in the intra-abdominal hypertension (IAH) management algorithm.

Aim: To test POCUS in the medical management of patients with IAH.

Method: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management.

Result: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65±22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (5 cases). Ultrasound and abdominal X-rays were comparable in confirming nasogastric tube (NGT)'s correct position, but the ultrasound was superior in determining the gastric content (fluid vs solid) and diagnoses of gastric paresis in 2 cases. Small bowel obstruction was present in four patients and confirmed with computerized tomography (CT) abdomen, and 2 of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely in 72%, 56%, and 42% of the times on days 1, 2, and 3. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites and ultrasound (US)-guided paracentesis performed.

Conclusion: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.

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Pneumomediastinum diagnosed from a remote tele-ICU center?

Authors: Keith Azevedo, Brian T. Wessman

Abstract

Background: The propagation of remote “telemedicine” has allowed intensivists (and other medical professions) to expand their ability to provide critical care medicine services to intensive care units (ICUs). The physical exam is a pertinent skill that all providers learn early in their medical careers. Key components of the physical exam can help a clinician narrow the differential diagnosis. Even with modern monitoring devices and high-powered imaging, it is hard to replicate the physical exam on a critical care patient from a tele-medicine center.

Case presentation: An experienced intensivist working in a telemedicine (Tele-ICU) center reviewed the daily chest radiograph on a patient with a complex prolonged ICU course. The radiograph was immediately recognized as being concerning for an acute case of pneumomediastinum in a patient with recent tracheostomy manipulation. However, the intensivist was unable to corroborate his suspicions with a good physical exam as the differential diagnosis list was explored.

Conclusions: Acute pneumomediastinum is a severe disease process arising from numerous etiologies that can be life threatening. This disease process can often times be diagnosed from plain chest radiography alone. However remote telemedicine patient care should never supersede a direct bedside physical exam. Every good clinician knows that the fundamental physical exam truly is fundamental.

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Critical care medicine ocular emergency presentation: Can you see it?

Authors: Stephanie Charshafian, Brian T. Wessman

Abstract

Introduction: Ocular emergencies are not a common presentation in the intensive care unit. Intensivists should have a broad differential for the “red eye” and involve ophthalmology appropriately for ocular emergencies.

Background: Ocular emergencies can lead to permanent vision loss if not identified in a timely fashion.

Case description: A patient with hyponatremia and bacteremia admitted to the intensive care unit (ICU) developed an acute painful red eye. Physical exam findings and images are shared.

Conclusion: Due to an acute ocular emergency, this critically-ill patient required transfer to a higher level of care and subspecialty management.

Clinical significance: Education about ocular emergencies is provided for the intensivist; including diagnosis, management, and complications.

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