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15th International Symposium on Critical Care and Emergency Medicine

The symposium will be held in Kuta, Bali, Indonesia.
Kuta’s claim to fame owes much to two things: its beach (originally Bali’s best) and the simply magnificent sunset. A part from surfing on its huge breakers and strolling for miles on the pearly white beach, shopping is a must with the wide variety and number of shops and street vendors selling rattan bags batik shirts and a range of other interesting mementos.


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BCA Cabang Wisma Asia
Beneficiary name: Luciana Budiati Sutanto
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Mineral Oil: The Occult Cause of Critical Illness

A 59 year-old lady with a history of diabetes,
hypertension, and coronary artery disease presented to
the emergency department complaining of progressive
shortness of breath over a 6 month period. On initial
examination she was found to be hypoxemic with a
PaO² of 50 mmHg. A chest radiograph left lower lobe
consolidation (Figure 1). The patient was given broadspectrum
antibiotics and admitted to the intensive care
unit (ICU). In the ICU she remained on antibiotics
and bronchodilator therapy was started. Despite these
interventions, she showed no evidence of improvement
over next 48 hours.
Additional questioning revealed that the patient
had a history of chronic constipation for which she had
been using mineral oil as a laxative over the last decade.
A computed tomography (CT) scan of chest revealed
a large area of consolidation extending from the left
hilum into the left lower lobe with satellite nodules in
the left lower lobe (Figure 2). The patient underwent
bronchoscopy with bronchoalveolar lavage, which
showed mucin with intermixed degenerated epithelial
elements and focal foamy histiocytes. Transbronhcial
biopsies of the region yielded moderate patchy to
diffuse infi ltrate of multi-vacuolated histiocytes,
with occasional foreign body giant cells. The Sudan
black stain was positive. These fi ndings corroborated
a suspicion of lipoid pneumonia. Antibiotics were
stopped at that time. A follow up chest x-ray showed
improvement over 3 months with resolution of infi ltrate
over 6 months.
Lipoid pneumonia occurs mainly in children
and the elderly, who are at risk for aspiration. Because
of its high viscosity, mineral oil depresses the cough
refl exes, facilitating aspiration even in normal persons,
and patients with swallowing dysfunction are at an
increased risk. This condition can be underdiagnosed
as mineral oil is often not considered important by the
patient to be listed with the medications which they are
taking.


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Gastric Strongyloides with Ulceration and Klebsiella pneumonia Bacteraemia

Strongyloides infection is usually confi ned to small intestine in gastrointestinal tract. Gastric mucosal Strongyloides with ulceration is extremely uncommon. We describe a patient who presented with gastrointestinal bleeding with gastric Strongyloides diagnosed by biopsy from the base of the gastric ulcer. Patient was treated with ivermectin 9 mg once a day for 2 days. The hospital stay was complicated by severe Klebsiella pneumoniae bacteraemia which needed treatment with meropenem for 2 weeks. Patient was discharged after 40 days of hospital stay.


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Effectiveness Study of rHuEPO in the ICU

Purpose: To evaluate the clinical outcomes and resource use in ICU patients receiving rHuEPO in a naturalistic setting. Methods: A retrospective, case-matched (1:2 ratio) study compared patients receiving rHuEPO to a control group. Patients admitted between January 2000 and July 2002 with an ICU length of stay (LOS) ¡Ý3 days were identifi ed by an electronic data repository. Patients, who received rHuEPO prior to ICU admission, had chronic renal failure or were <18 years of age were excluded. Patients were matched by age (¡À5 years), sex, admission year and ICU type. Collected data included patient demographics, admission date, ICU and hospital mortality and LOS, mechanical ventilation days, serum creatinine concentration, hemoglobin concentration, number of blood transfusions, and ICU resource use. Results: rHuEPO-treated patients (n=391) were matched with 782 controls. Patients receiving rHuEPO had higher Simplifi ed Acute Physiology Scores II (46.2 vs 38.8; p <0.001) and received signifi cantly more blood transfusions than control patients (19 vs 6; p <0.001). After adjusting for severity of illness in a linear regression model, rHuEPO was signifi cantly associated with increased blood transfusions and higher mortality risk. Patients receiving rHuEPO had signifi cantly longer hospital and ICU LOS, mechanical ventilation duration, and higher hospital and ICU mortality rate and hospital resource use (p <0.001). Conclusions: In this real-world retrospective analysis, critically ill patients treated with rHuEPO did not experience clinical benefi ts; however, patients were sicker and received rHuEPO late in their ICU stay. Monitoring prescribing patterns and patient selection of rHuEPO treatment in critically ill patients in clinical practice is recommended to optimize rHuEPO use and outcomes.


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Critical Care of the Liver Transplant ICU Patients: A Pittsburgh “Point of View”

The purpose of this review is to summarize the advances in critical care management of the liver transplant ICU patients (patients with end stage liver disease, before and after orthotopic liver transplant). The review is based on search of Medline literature, with a focus on liver failure patients and critical care issues around liver transplantation. Starzl Transplantation Institute at the University of Pittsburgh Medical Center is one of the global leaders in the treatment of end stage liver disease (ESLD). This review is in part based on our work in the 28-bed liver transplant ICU at Montefi ore Hospital, University of Pittsburgh Medical Center, in Pittsburgh, PA. Over the past few years, our understanding of the several important pathophysiologic markers of end stage liver disease has been signifi cantly improved. For example, we do now much better understand hyperdynamic circulation of liver failure, hepatorenal syndrome and its consequences, the role of TIPSS (transjugular intrahepatic portosystemic shunt) and adrenal insuffi ciency in liver failure patients. The management and prophylaxis of variceal bleeding and subacute bacterial peritonitis (SBP), has been successfully standardized. These and other advances in understanding of ESLD pathophysiology and its clinical results, have certainly contributed to more promising outcomes in the ICU management of these complex patients.


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Abdominal Sarcoidosis

Abdominal sarcoidosis is an uncommon form of sarcoidosis. The clinical presentation of esophageal, gastric, small bowel, colon, appendicular, spleen, pancreas, and abdominal aortic sarcoidosis are discussed in this review. The differential diagnosis of abdominal sarcoidosis is extensive. Other granulomatous diseases including tuberculosis, fungal infections, parasitic diseases, infl ammatory bowel disease, and Whipple’s disease should be excluded before making the diagnosis of gastrointestinal sarcoidosis. Corticosteroid therapy is the mainstay of medical therapy in abdominal sarcoidosis. Second line agents such as methotrexate are also discussed. Surgical intervention may be necessary in patients with bowel obstruction, perforation, or massive hemorrhage. The authors also provide their experience regarding preoperative pulmonary evaluation of patients with pulmonary sarcoidosis undergoing surgery.


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