Acute ischemic stroke - an extrapulmonary COVID-19 presentation
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) has emerged as a high contagious and deadly virus, with an endless capacity to surprise clinicians with new presentations and complications. Although COVID-19 typically presents as respiratory infection but it can present with thromboembolic event. Our hospital, one of the main territory care hospitals in Kuwait, experiencing sudden surge of stroke cases in last few weeks of COVID-19 pandemic. Stroke is a medical emergency which needs early recognition and management for better neurological outcome. In the COVID-19 pandemic, when seeing patients with neurological manifestations, clinicians should consider COVID-19 as a differential diagnosis and should take full protective measures until proven to be negative. Based on our experience, we want to highlight that COVID-19 patients can present with extrapulmonary manifestation like stroke. Emergency physicians, stroke team and intensivist should be wary of this fact. Triaging and COVID-19 screening is the key to minimize the virus spread and to ensure staff and other patients safety.
Renal angina index in pediatric septic patients as a predictor of acute kidney injury in remote area
Abstract
Background: One of the most common sepsis comorbidities is severe acute kidney injury (AKI), which occurs in about 20% of pediatric patients with severe sepsis and is independently associated with poor outcomes. Many studies have shown the ability of renal angina index (RAI) with a cut-off point of 8 to predict the risk of AKI grade 2 and 3, but with varying sensitivity and specificity. Therefore, this study aims to identify a RAI cut-off point to predict the incidence of AKI in pediatric septic patients in the setting of a regional hospital in Indonesia.
Methods: An observational analytic study with a prospective longitudinal design was conducted on 30 pediatric patients in the Resuscitation Room of Dr. Soetomo General Hospital Surabaya. Patients who met the inclusion criteria were given 1-hour standardized resuscitation, then were observed. Every action taken to the patient was recorded, fluid input and output were measured, and mechanical ventilation and vasopressor administration were documented until the third day to determine factors influencing the incidence of AKI.
Results: In this study, 56.7% of pediatric septic patients had AKI. The Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in this study had a median of 11, in accordance with the pediatric sepsis guideline. RAI, with a cut-off point of 8 as a predictor for AKI grade 2-3, had a sensitivity of 100% and a specificity of 68% (area under the curve [AUC]=0.912). In terms of AKI risk tranche, the majority of patients (93.1%) had mechanical ventilation, while in terms of AKI injury tranche, the majority met the fluid overload criteria (79.3%).
Conclusion: RAI, with a cut-off point of 8, can be used as a predictor for severe AKI in pediatric septic patients.
Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: A randomized, double-blind controlled trial
Abstract
Objective: Initial fluid resuscitation is mandatory in treatment of septic shock. Current sepsis guidelines do not have the recommendation for either balanced salt or normal saline solution for initial fluid resuscitation. The objective of this study was to determine the impact of balanced salt solution (BS) versus normal saline solution (NS) in pediatric septic shock as initial fluid resuscitation.
Design: A double-blind randomized controlled trial study.
Setting: A single tertiary care center in Bangkok, Thailand.
Patients and participants: Children aged 1 month to 18 years who were diagnosed with septic shock. We excluded patients who received fluid resuscitation in the 24 hours prior to septic shock, end-stage disease, and refusal of informed consent.
Interventions: Patients were randomly assigned into 2 groups after being diagnosed with septic shock and required fluid resuscitation (NS or BS).
Measurements and results: Demographic data, vasoactive-inotropic scores, and outcomes were evaluated. The primary outcome was incidence of hyperchloremic metabolic acidosis. Sixty-one septic shock children were enrolled into this study (NS=31 patients, and BS=30 patients). Baseline characteristics between two groups were not different. The incidence of hyperchlor-emic metabolic acidosis was 17 (54.8%) and 10 (33.3%) in NS and BS groups, respectively (p=0.091). The hospital mortality and prevalence of acute kidney injury were not different between groups.
Conclusion: In pediatric septic shock, the initial fluid resuscitation with balanced salt solution and normal saline was associated with similar clinical outcomes. However, normal saline solution had a trend toward more frequent hyperchloremic metabolic acidosis in children with septic shock when compared to balanced salt solution.
Predicting the circulation’s response to fluid resuscitation
Abstract
Fluid resucitation plays a crucial role in pediatric resuscitation. Predicting fluid responsiveness is important as excessive fluid may decrease cardiac efficiency, and even induce overload. Various pathophysiology of shock suggest that fluid only benefit in optimizing preload. Various methods to assess fluid responsiveness includes measurement of static preload indices, dynamic indices to estimate volume status, and the use of protocols such as fluid challenge and passive leg raising technique. This paper highlights the mechanisms behind each measurements and summarized their use as predictor of fluid responsiveness in pediatric patients.
Toxic shock syndrome related to the use of a menstrual cup in a pediatric patient
Abstract
Menstrual cups, made of hypoallergenic rubber or silicone, were first marketed in the 1930’s but have become increasingly popular. Menstrual cups may be less expensive, more environmentally friendly and potentially a safer alternative to tampons and menstrual pads, although the safety of these cups is unknown. We report a case of a 17.5-year-old female who developed probable toxic shock syndrome related to use of The DivaCup®. We suggest that women presenting with signs and symptoms of toxic shock syndrome be asked specifically about their use of a menstrual cup in addition to tampons, because it may be a risk factor and present requires prompt removal for source control.
Cerebral pontine infarction after postpartum hemorrhagic shock
Abstract
Cerebral pontine infarction is a rare complication of hemorrhagic shock. We report an unconscious 30-year-old woman that was admitted with severe postpartum hemorrhage (PPH). The patient required two surgery to control the bleeding. Focal neurologic deficit was recognized after extubation. Computed tomography (CT) scan showed findings which were consistent with acute right-side pontine infarction. The patient’s symptoms improved with anti-thrombotic therapy and she was discharged on the thirteenth day of hospitalization. A routine stroke rehabilitation program was planned.