Significantly Raised Brain Natriuretic Peptide in a Young Patient with Dengue Fever without Heart and Renal Failure
Objective: This is the fi rst case report of association of raised brain natriuretic peptide (BNP) in patients with dengue fever (DF). BNP is raised in patients with heart failure. It can also be elevated in renal failure and subarachnoid haemorrhage in the absence of heart failure. Raised BNP has never been described in patients with DF. Clinical features: We describe a young patient with DF who complained of sudden onset breathlessness on day 3 of admission. She was found to have right sided crepitations. Myocardial screen was done which was negative but BNP was 3555 pg/ml. Her SpO2 and arterial blood gas while breathing room air was normal. There was no elevated jugular venous pressure, pedal edema or laboratory evidence of heart failure. There was no renal impairment or systemic infl ammatory response syndrome. A transthoracic 2-dimensional echocardiography was normal. Treatment: Patient was treated with intravenous fl uids and oral clarithromycin for 5 days. Outcome: Patient was discharged on day 8 of admission. She was well but follow-up BNP was high but on downward trend. She refused any further invasive investigations for heart. Conclusions: BNP may be raised in patient with DF without heart failure. The exact pathogenesis of raised BNP in DF is unclear.
Unilateral Diaphragmatic Pacing: An Innovative Solution for Unilateral Diaphragmatic Paralysis
Mechanical ventilation has always been a cornerstone of respiratory support for patients with respiratory muscle paralysis. In selected patients, diaphragm pacing (DP) through electrical stimulation of the phrenic nerves provides an alternative to mechanical ventilation with signifi cant advantages in life quality. We report an interesting case of unilateral diaphragmatic paralysis in which unilateral diaphragmatic pacing produced signifi cant improvement in quality of life.
Acid-Base Disturbance Analysis: Comparison of the Traditional and Stewart Approaches
Introduction: The new approach to acid-base balance which initially proposed by Stewart in 1978 was success to provide a new insight which more easy to understand what is the cause, the mechanism and the degree of acid-base disturbance. The purpose of the present study was to compare two different methods of analysis acid-base disturbance in patients admitted to Pediatric Intensive Care Unit (PICU). Methods: The study was performed in 43 patients admitted to the pediatric intensive care unit of Cipto Mangunkusumo Hospital, Jakarta. Sodium, potassium, chloride, albumin, lactate and arterial blood gases were measured. All samples were taken from artery in every patient. The anion gap (AG) was calculated using the Narins method (1977), the corrected anion gap (AGcorr) using the Moviat method (2003), the strong ion gap (SIG) using Kellum method (1995) and the base excess unmeasured anions (BEUA) using the Fencl-Stewart method simplifi ed by Story (2003). Results: The presence of unmeasured ions identifi ed by signifi cantly abnormal BEUA was poorly identifi ed by SBE. Of the 43 patients included in the study, 18 (41.9%) had a different interpretation of acid-base balance when the Fencl-Stewart method was used compared to using SBE. There was good correlation between SIG and AG (r =0.831), and there was excellent correlation between SIG and AGcorr (r =0.991). Conclusions: In the condition of electrolyte unbalance and hypoalbuminemia the Stewart approach is better than the traditional approach. Nevertheless, the calculation of SIG is more timeconsuming, therefore the corrected anion gap (AGcorr) was suggested to use in clinical practice as a combination with SBE.
Extra-Pulmonary Sarcoidosis: Neurosarcoidosis – Case Presentation and Literature Review
More than a century after the description of sarcoidosis, the disease remains not well understood. Sarcoidosis is an infl ammatory disease of unknown etiology characterized by noncaseating granulomas with multiple organs affected. The epidemiology reveals lung involvement in 90- 95% of the patients and just 5-13% incidence of neurological involvement. We present an unusual case of a patient with medulla oblongata and retroperitoneal sarcoidosis with no other organ involvement. In addition to the case presentation and extensive up-to-date literature review on extrapulmonary sarcoidosis, we describe the diffi culties in making the diagnosis and the challenge in differentiating sarcoidosis from other illnesses such as tuberculosis.
Non Infectious Pulmonary Complications after Bone Marrow Transplant with a Special Focus on Idiopathic Pneumonia Syndrome
Pulmonary complications are a signifi cant cause of early mortality (up to 100 days) after hematopoietic stem cell transplantation (HSCT). While infectious complications particularly due to opportunistic pathogens are common in these patients, diffuse lung injury is a non-infectious complication occurring in 25-50% of HSCT recipients. The incidence of this complication is higher with allogeneic as apposed to autologous transplants and is largely dependant on the method of graft versus host prophylaxis. The spectrum includes interstitial pneumonitis (IP), bronchiolitis obliterans (BO), diffuse alveolar hemorrhage (DAH) and noncardiogenic capillary leak syndrome (NCLS). In 1993 a panel convened by the National Institutes of Health (NIH) defi ned widespread alveolar injury following HSCT that occurs in the absence of an active lower respiratory tract infection and cardiogenic causes as the idiopathic pneumonia syndrome (IPS). IPS is a clinical syndrome with variable histopathologic correlates and several potential etiologies. Peri-engraftment respiratory distress syndrome (PERDS) and delayed pulmonary toxicity syndrome (DPTS) are also included within the defi nition of IPS. Histopathologic fi ndings associated with IPS include diffuse alveolar damage with hyaline membranes, lymphocytic bronchitis and bronchiolitis obliterans organizing pneumonia (BOOP). The pathophysiology involves four distinct mechanisms, namely: the toxic effects of chemotherapy, immune dysregulation, alloreactive donor cells and host cell responses. The roles of lipopolysaccharide (LPS), monocyte chemoattractant protein-1 (MCP-1) and tumor necrosis factor (TNF) in the genesis of endothelial cell injury are being defi ned. Therapy for IPS includes supportive care and immunosuppressive agents. The role of TNF antagonists is being studied in ongoing clinical trials.
Pro- and Anti-Infl ammatory Balance of Septic Patients is Associated with Severity and Outcome
Purpose: To study infl ammatory profile in patients with sepsis, severe sepsis and septic shock with regards to organ dysfunction and outcome, and to identify a pattern associated with more catastrophic course of illness, organ failure and risk of death. Material and methods: Twenty-nine consecutive patients with sepsis admitted to a medical Intensive Care Unit of a tertiary university hospital (November 2002-December 2003). Plasmatic levels of interleukin-6 (IL-6) and interleukin-10 (IL- 10) as pro-infl ammatory and anti-infl ammatory markers were measured at baseline, 12, 24 and 48 hours of evolution. Results: There is a positive association between higher levels of IL-6 and severity of the septic process, organ dysfunctions and risk of death, statistically signifi cant at anytime (at baseline, 12, 24 and 48 hours, p <0.05). Higher IL-6/IL-10 ratios associate signifi cantly with risk of death at 24 hours (RR=1.45 if higher or equal to the median). Conclusions: Plasmatic biomarkers measurement during the initial phase of sepsis may help to individualize therapy. An evaluation at 24 h based on IL-6/IL-10 ratio may anticipate a more aggressive infl ammatory profi le. These patients would specially benefi t from immunomodulating therapies to improve survival.
Use and Understanding of Therapeutic Hypothermia in Developing Countries
Purpose: The use of therapeutic hypothermia (TH) has increased in the treatment of comatose victims of cardiac arrest, traumatic brain injury, refractory dysrhythmias, neonatal encephalopathy and asphyxia, near-drowning and hemorrhagic shock. The purpose of this study was to ascertain the level of understanding of TH use for comatose victims of cardiac arrest among healthcare providers in two developing countries. Methods: A 22-question survey was administered to physicians, nurses, and other health professionals who attended two large emergency medicine and critical care meetings in Indonesia and Mexico. The questionnaire included socio-demographic characteristics of the respondents. Specifi c questions regarding TH awareness and its use were included, as well as questions examining familiarity with the current recommendations from International Liaison Committee on Resuscitation (ILCOR) Results: Two hundred and sixty-six surveys were collected from the two countries. Of all respondents, 15.54% had used TH: 37.8% were nurses and 31.58% physicians (ñ =0.012). TH was used most frequently administered in the coronary care unit and the emergency department (55% and 45%, ñ =0.005). Eight percent of all respondents had TH protocols established at their institutions, mostly by nursing personnel (80% ñ =0.009). Practitioners reported they were not familiar with the ILCOR guidelines (97% of the respondents from Mexico and 87% of the respondents from Indonesia (ñ =0.009)). Among those using TH, active rewarming was used by 71% of respondents queried in Indonesia as compared with 38% of respondents surveyed in Mexico (ñ =0.001). Conclusions: TH appears underutilized in our sample of practitioners from two developing countries. Clinicians in these countries are not familiar with ILCOR TH guidelines. Therapeutic hypothermia is certainly practical in most clinical settings and programs aimed at educating practitioners about TH are needed in developing countries to improve neurological outcome in comatose victims of cardiac arrest.
14th International Symposium fo Critical Care and Shock
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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.
Effectiveness Study of rHuEPO in the ICU
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.