Acute necrotizing pancreatitis associated with Covid-19: A case report


Coronavirus infection is commonly associated with pulmonary manifestations. Extra pulmonary manifestations including gastrointestinal involvement is also well established recently in COVID positive patients. However, pancreatic involvement due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is an unusual presentation and therefore much more attention has to be given to the pancreatic injury caused by SARS-CoV-2 infection. There is different pathophysiology behind the pancreatic dysfunction associated with SARS-CoV-2 infection. It can either be the systematic inflammatory immune response causing tissue damage or direct invasion of pancreatic cells. The virus enters the host cells or tissues via its spike protein that binds to the angiotensin-converting enzyme 2 (ACE2) present in the pancreatic islets cells, which in turn leads to pancreatic injury and dysfunction. It can also occur as an adverse effect of medications like ritonavir-lopinavir that is a therapeutic option for COVID-19 patients. Here, we report a case of a patient with COVID-19-induced acute pancreatitis where medical history and further investigations eliminated all the other expected causes of pancreatitis. He came with complaints of hiccups for two weeks and abdominal pain. He tested positive for COVID-19 and was managed with antibiotics like meropenem. Laboratory investigations as well as computed tomography abdomen paved way for the detection of pancreatic involvement. Pancreatic injury and COVID-19 infection were resolved during the course in hospital and the patient was discharged on medications including zinc, vitamin C supplementation, and also with ciprofloxacin.

Authors: Ameya B., Mahima A., Anju G., Nirmal KP, Uma Devi P., Rajesh G., Priya Nair, Dipu TS, Merlin Moni, Shine S.

Calciphylaxis: A case report and literature review


Necrotising fasciitis is an extremely life-threatening condition, which mainly develop from the necrosis of the subcutaneous fascia and adjacent tissue. It can be caused recurrently from moderate to severe systemic toxicity and be fatal due to lack of medical or surgical treatment. Any absence of particular clinical features can easily result in the under diagnosis such as cellulites or abscess.

The infection can be caused by one or more micro-organisms, both aerobic and anaerobic. Calciphylaxis or calcific uremic arteriolopathy (CUA) is a rare limb threatening condition commonly seen in renal disease patients. It is commonly caused by the accumulation of calcium deposits in the subcutaneous tissue and in the small arteries. Hence, we report a case of 50-year-old female with necrotising fasciitis who was diagnosed with a very rare condition of calciphylaxis.

Authors: Aishwarya Rajeev, Roshni PR

Role of vasopressin in hyponatremic dehydration


Excessive correction of hyponatremia frequently occurs in the management of hyponatremic dehydration. This is more common in infants when correction of dehydration rapidly covers the hyponatremia faster than desired. This is the case of a 2½-month-old male infant with hyponatremic dehydration, which was overcorrected during the initial phase of treatment and was later managed by subcutaneous vasopressin. Vasopressin has got a dual role in the management of hyponatremic dehydration as it helps in dehydration correction as well as slow correction of sodium.

Authors: Anna Kurian, Sruthi G., Sajith Kesavan, Roshni PR

High capillary leak index is associated with increased risk of ICU-related mortality after major abdominal surgery


Objective: Major surgery may induce an inflammatory response, which results in an increased level of C-reactive protein (CRP) and represented in albumin loss to extravascular area due to increased capillary permeability. Our study was to evaluate the association between capillary leak index (CLI) and intensive care unit (ICU)-related mortality in patients underwent major abdominal surgery.

Design: This was a prospective study with cohort analytic design.

Patients and participants: We included adult patients aged 18 and older who were treated in ICU after underwent major abdominal surgery. Patients who were pregnant, having menstruation, relaparotomy, diabetes mellitus, and idiopathic systemic capillary leak syndrome were excluded from this study. Blood was collected before surgery and at 48 and 72 hours after surgery. Patients were observed for mortality incidence during treatment in the unit. The CRP level was measured using ABX Pentra 400 (HORIBA, Germany), whereas the albumin level was measured using HumaStar 80 (HUMAN, Germany). CLI was measured by dividing CRP level by albumin level. Data were analyzed using SPSS Statistics version 21.0 (IBM, New York, U.S.).

Results: CLI at hour 72 was associated with increased risk of ICU-related mortality (RR 21.667; 95% CI 2.938-159.763; p<0.001).

Discussion: Acute inflammation normally resolved within three days. Systematic response to tissue injury, including major surgery, is marked by increased proinflammatory cytokines, which promotes CRP production and capillary leakage. CRP production will increase to its peak level 36-50 hours after inflammation. However, if the injury still exists, inflammatory process will continue.

Conclusions: High CLI at hour 72 can be considered as the risk factor to ICU-related mortality.

Authors: Ade Susanti, Mayang Indah Lestari, Sedono R, Liberty IA

Thromboelastography (TEG) and hemostatic parameters as the diagnostic parameter of septic mortality in the intensive care unit


Objective: This study aimed to determine the relationship between thromboelastography (TEG) and hemostatic parameters and the Sequential Organ Failure Assessment (SOFA) score and mortality of septic patients, and found the potential of those parameters to be the mortality diagnostic parameters.

Design: This was a prospective cohort study.

Setting: This study was conducted in the Intensive Care Unit of Dr. Saiful Anwar General Hospital.

Patients and participant: This study was conducted on thirty septic patients at the Intensive Care Unit.

Measurement and result: Hemostatic parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR]) and thromboelastography parameters (R time, K time, α angle, maximum amplitude [MA], G value, coagulation index [CI], and LY30) were analyzed using the normality test, homogeneity test, t-test, correlation test, and receiver operating characteristic (ROC) curve test in SPSS version 17.0. SOFA scores 8-11 and 12-20 had the highest mortality (100%). R time, K time, CI, α angle, MA, and G value, and all hemostatic parameters significantly correlated with SOFA score (p<0.05). R time, K time, α angle, CI, PT, aPTT, and INR of living patients significantly differed from death patients (p<0.001). K time, α angle, MA, CI, and all hemostatic parameters had an area under the curve (AUC) close to 1 (p<0.05). K time (69.2%) and aPTT (100%) had the highest sensitivity. The positive predictive value (PPV) of all TEG parameters was 100%. aPTT (100%) was the highest in the hemostatic parameters. The hemostatic parameters had a higher sensitivity than its specificity, while the TEG had higher specificity than its sensitivity.

Conclusion: Most thromboelastography parameters and all hemostatic parameters significantly correlated with the SOFA score. K time had the highest sensitivity and specificity as the diagnostic parameter of septic mortality compared to the other thromboelastography parameters, while aPTT was the most sensitive diagnostic parameter of septic mortality compared to other hemostatic parameters.

Authors: Isngadi, Aswoco Andyk Asmoro, Harjuna Atma Wiraharjanegara, Arie Zainul Fatoni

Positive cumulative fluid balance is a risk factor of mortality in critically septic patients


Objective: Excessive fluid administration may increase septic patient mortality. Cumulative fluid balance is an easy, cheap, and non-invasive method of monitoring fluid therapy. Our study aimed to analyze the association between cumulative fluid balance and mortality in critically septic patient.

Design: This was an observational analytic study with a retrospective cohort design.

Setting: This study was conducted in intensive care unit of Mohammad Hoesin Hospital in 2017.

Patients and participants: All adult septic patients from January to December 2017 were included. All patients who did not have completed medical record data were excluded.

Interventions: Data on the mortality and cumulative fluid balance of septic patients were obtained through secondary medical record data and were analyzed using SPSS Statistics version 22.0 (IBM, New York, US).

Measurement and results: Positive cumulative fluid has a very significant association with mortality (relative risk [RR] 3.41; 95% confidence interval [CI] 1.98-5.87; p<0.001). Mean cumulative fluid balance (ml) were greater in non-survivor than survivor group (1937.5±1692.6 vs 877.2±1228). The probability of survival in 28 days was affected by cumulative fluid balance (p=0.001) after being tested with Mantel Haenszel log-rank test. This cumulative fluid balance had a sensitivity of 81.8% and specificity of 89.2% as a predictor of mortality in septic patients.

Conclusions: Positive cumulative fluid balance can be considered as the risk factor to septic patient mortality.

Authors: V. Linardi, SE Handrawan, P. Liana, Mayang Indah Lestari

From the Editors: Introducing our New Website

Dear Readers and Authors,

Critical Care and Shock started as a peer-reviewed journal in 1998 by Dr. Iqbal Mustafa, together with several colleagues, with the specific aim of advancing acute and critical care medicine in the Asia Pacific area as well as other parts of the World due to the increasing popularity of unique therapeutic interventions for critically ill patients.

Unfortunately, Dr. Iqbal Mustafa was unable to continue his mission due to his sudden death on 18 July 2004. We knew he was no longer among us, but his spirit remained among many of his colleagues. Professor Xavier Leverve played an important role in the establishment of Critical Care and Shock and was entrusted to be the Editor-in-Chief replacing Dr. Iqbal Mustafa. In another great loss for humanity, Professor Leverve left us all after 6 years of carrying out his outstanding duties. At that point, Professor Joseph Varon, who had also been involved in this Journal since its founding,  agreed to lead this Journal as Editor-in-Chief and has done so uninterrupted since then.

For over 20 years we have published high-quality peer-reviewed articles in the fields of acute and intensive care medicine. During that period of time, we continue to strive to provide the best academic platform for researchers, educators, and our loyal readers. As the Journal evolved, so did its design. For example, in 2006 we introduced a new color scheme for the Journal with the intention of expressing our desire that the articles submitted bring new and original information of general interest to practitioners dealing with acute and critically ill patients.

We continue to innovate the Journal and its website and try to be at the forefront of scientific publications. Effective December 2021, we are introducing our redesigned website, which we hope can further support our vision and mission in treating acute and critically ill patients around the globe. The website design was created to make access to the Journal easy and the submission process simplified. We realize there are shortcomings here and there, and we appreciate all the input we have received to make this site author- and reader-friendly. We truly hope you enjoy this redesigned website and that you continue to submit your scientific contributions to Critical Care and Shock.

December 2021,

Professor Joseph Varon, MD, FACP, FCCP, FCCM, FRSM                          Simon Nanlohy, MD

Editor-in-Chief                                                                                                 Managing Editor

Authors: Joseph Varon, Simon Nanlohy