The effectiveness of noninvasive ventilation in myasthenia gravis patients with respiratory failure in reducing the need of endotracheal intubation and increase extubation outcomes


Background: Myasthenia gravis is characterized by muscle weakness and fatigability. The affected muscle are ocular muscle, oropharyngeal muscle, facial muscle, and respiratory muscle. This leads to respiratory failure in myasthenia gravis patients with myasthenic crisis. Noninvasive ventilation has been used to treat patients with hypercapnia respiratory failure and associated with reduction of the need of endotracheal intubation, reduction of complication rate, reduction of hospital stays, and reduction of mortality. In myasthenia gravis patients with respiratory failure, there is no evidence that noninvasive ventilation would reduce those factors. Thus, we studied the effectiveness of noninvasive ventilation in myasthenia gravis patients with respiratory failure in reducing the need of endotracheal intubation and increase extubation outcomes.

Methods: Literature review on PubMed, Elton B. Stephens Co. (EBSCO), Cochrane, and ScienceDirect yield two relevant articles.

Results: Two studies showed that noninvasive ventilation in subject with myasthenia gravis with respiratory failure had better effect.

Conclusion: It is effective to use noninvasive ventilation in subject with myasthenia gravis during their respiratory failure in myasthenic crisis.

Authors: Nadya Farhana, Zulkifli Amin

Carisoprodol intoxication: a comprehensive review


Carisoprodol has been widely used as a muscle relaxant agent. In Indonesia, carisoprodol is well-known as carnophene/zenith. Many retailers sell this drug illegally, especially to sex workers to make them feel more relaxed. Due to high incidence of carisoprodol abuse, Drug Enforcement Administration (DEA) categorized it into Schedule IV. Knowledge about pharmacokinetic and pharmacodynamic of carisoprodol are essential to be understood for proper diagnosis and management. Until now, there are only a few case reports about carisoprodol intoxication and no guideline has been published. This article aims to provide an overview about carisoprodol intoxication, starting from the mechanism of action to its management. In the body, carisoprodol is metabolized to meprobamate by CYP2C19 liver enzyme. Diagnosis of carisoprodol intoxication is challenging because carisoprodol and meprobamate have opposite effect. Gastric lavage, administration of flumazenil and bemegride may be effective for acute intoxication case.

Authors: Zulkifli Amin, Steven Zulkifly, Stephen Diah Iskandar

The use of furosemide in critically ill patients


Critically ill patients are those with life threatening illness who, without adequate medical interventions, will suffer from severe morbidity and occasionally mortality. One of the most frequent cause of morbidity and mortality in critically ill patients is distributive or vasogenic shock. After liberal fluid resuscitation, an increase in microvascular hydrostatic pressure, fluid accumulation of interstitial compartment, and impaired organ function occur. Normally this phase, called ebb phase, will return to flow phase where inflammatory mediators homeostasis occurs, plasma oncotic pressure restored, diuresis, extravascular fluid mobilized and negative fluid balance occur. In certain group of patients, there is persistent systemic inflammation, plasma leakage, and failure to achieve flow phase spontaneously, which lead to fluid overload and global increased permeability syndrome (GIPS). GIPS causes venous resistance of organs within compartment, resulting in decreased perfusion pressure and organ failure. In this condition, it is necessary to remove the fluid actively and one of the drugs that can be used is furosemide. This literature review will describe what happens in critically ill patients, how furosemide works, what its benefits are in critically ill patients, what side effects and potential toxicities of furosemide.

Authors: Mayang Indah Lestari, Yohannes WH George

Accuracy of calculated creatinine among amputees: case presentation and literature review


Dosing vancomycin for patients who do not follow population pharmacokinetics can be challenging. Standard predictive clinical equations do not account for extreme patient characteristics. In particular, serum creatinine is significantly reduced while creatinine clearance is overestimated in patients with amputations. The “missing” body part must be accounted for when executing a dosing regimen for these challenging patients. In addition, health care professionals must judiciously review the patient holistically, practice evidence-based medicine, and consider the overestimation of renal function, when calculating doses for this and other agents. While current literature does not provide a clear consensus for this population, there are several factors to take into consideration when determining the optimal dose in patients presenting to the hospital requiring medications dosed by changes in renal function. We recently had one such case.

Authors: Janay Bailey, Elizabeth Awudi, Charlene Kalani, George Udeani, Joseph Varon, Salim Surani

Sodium bicarbonate buffering for metabolic acidosis does not hasten hemodynamic improvement in septic shock: a retrospective analysis of a 5-year period


Objective: Severe metabolic acidosis often occurs in the setting of septic shock and hemodynamic collapse. Acid buffering agents such as sodium bicarbonate are often used to improve acidosis, although the hemodynamic benefit of improving the serum pH is uncertain and has been evaluated only in a few small clinical studies.

Design: A retrospective cohort of patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate.

Setting: A single-center mixed medical-cardiac-surgical intensive care unit.

Patients and participants: 21 patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate. Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate served as a matched control group.

Interventions: The primary endpoint was the change in norepinephrine equivalent (NEEq) dose at 24 and 48 hours after initiation of sodium bicarbonate when compared to non-sodium bicarbonate treated patients. Secondary outcomes included: hospital mortality, the impact of hypocalcemia on vasopressor requirements, and the impact of hypercapnia on vasopressor requirements in sodium bicarbonate treated patients.

Measurements and results: Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate had no difference in the decline of vasopressor requirements than those administered sodium bicarbonate at 24 hours (0.09 μg/kg/min; 95% CI, [-0.23, 0.05], p=0.19) and at 48 hours (0.04 μg/kg/min; 95% CI [-0.11, 0.18], p=0.60). In patients with pH≤7.15, there was no difference in the change in NEEq dose between sodium bicarbonate treated or non-bicarbonate treated patients at 24 hours (0.05 μg/kg/min, 95% CI, [-0.09, 0.11], p=0.69) or at 48 hours (0.19 μg/kg/min, 95% CI, [-0.52, 0.14], p=0.17).

Conclusions: Administration of sodium bicarbonate did not improve vasopressor requirements at 24 or 48 hours, even in patients with a pH less than 7.15. Mortality and vasopressor needs are high in patients with pH less than 7.15 and unaffected by sodium bicarbonate administration.

Authors: John H. Ferguson, Maurice M. Otterstetter, Nicholas JK Tranchida, James DeFoe

Predictors of perceptions of patient safety culture and frequency of event reporting by critical care nurses in Oman: a model-building approach


Objectives: This study was conducted to identify the predictors of critical care nurses’ perceptions of patient safety culture and the frequency of event reporting.

Methods: A cross-sectional study design was used. Patient safety culture was assessed using the Hospital Survey on Patient Safety Culture, which was completed by 270 critical care nurses working in two hospitals in Oman.

Results: The results revealed that teamwork within units had the highest positive score (91.8%), followed by organisational learning and continuous improvement (86.3%) and feedback and communication about errors (77.7%). Regression analysis showed that teamwork within units, supervisor/manager expectations and actions promoting patient safety, organisational learning and continuous improvement, management support for patient safety, feedback and communication about errors, teamwork across units, staffing, hospital handoffs and transitions, and patient safety grade were all predictors of the overall perception of patient safety culture among critical care nurses in Oman (R2=0.462, adjusted R2=0.186; F=7.83, p<0.0001). Regression analysis showed that openness in communication, income, non-punitive response to errors, organisational learning and continuous improvement, and feedback and communication about errors were predictors of the frequency of events reporting among critical care nurses in Oman (R2=0.24, adjusted R2=0.043; F=3.41, p<0.0001).

Conclusion: Patient safety culture is an important indicator of the quality of care, and represents one of the key performance indicators in the healthcare setting.

Authors: Qasim Al Ma'mari, Loai Abu Sharour, Omar Al Omari

Eosinopenia as an indicator for organ dysfunction in septic patients


Sepsis is one of the most common causes of morbidity and mortality in intensive care unit (ICU).

Objective: To determine the possibility of eosinophil as indicator for organ dysfunctions in sepsis patients and septic shock patients in ICU.

Design: Prospective.

Setting: Intensive care unit (ICU) Wahidin Sudirohusodo Hospital, Makassar.

Participants: Adult sepsis patients admitted to ICU from October to December 2018.

Measurement: Eosinophils count and Sequential Organ Failure Assessment (SOFA) scores were assessed within 24 hours and after 72 hours after patients admitted in ICU. The patients were categorized into non- and organ dysfunction groups based on SOFA scores after 72 hours. Outcomes of the patients then evaluated at day 7.

Results: Thirty four sepsis patients participated in the study. The mean of SOFA scores between non- and organ dysfunction groups were not different within 24 hours after admission but then showed a difference after 72 hours (p=0.558 and p<0.001, respectively). In contrast with non-organ dysfunction patients, after 72 hours the eosinophil count in organ dysfunction group decreased (from 0.51 to 0.15 cells/µl). There was a negative correlation between eosinophil count and SOFA scores at 72 hours (p=0.043; rho: -0.350). In discriminating non-organ dysfunction and organ dysfunction groups, the area under the receiver operating characteristic curve was 0.714. Eosinophils at 0.5 cells/µl (eosinopenia) yielded a sensitivity of 92.8%, a specificity of 66.6%, a positive predictive value of 92.8%, and a negative predictive value of 66,6%.

Conclusion: Eosinopenia levels might be used as an indicator for organ dysfunction in critically ill patients, including sepsis patients, in area where laboratory facility is limited.

Authors: Syafri Kamsul Arif

Case series: two cases of life threatening dynamic airway obstruction from thyroid mass


We present 2 cases of dynamic airway obstruction with respiratory failure leading to cardiac arrest. Both have significant aetiology of cystic thyroid mass with sudden haemorrhagic changes leading to airway obstruction. We discuss the plausible pathophysiology leading to cardiopulmonary compromise where tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) play a significant role. We note that this is under recognised and can be present as a life-threatening event. Recognition of these pathophysiology process facilitate surgical management of thyroid obstructive airway disease.

Authors: Yeeshay Lee, Haozheng Wong, Sing Chee Tan, Rana Muhammad Habibullah, Yoke Yeow Yap, Faheem Khan, Chee Keat Tan

Barriers to effective in-hospital resuscitation: lessons learned during implementation of a hospital-wide code system


Aims and objectives: To understand the barriers involved in effecting a hospital-wide code system and overcoming them during implementation.

Background: Improving survival after in-hospital cardiac arrest involves standardization of both defibrillation equipment and staff's abilities during codes.

Design: Observational descriptive study.

Methods: Observational study of the situation existing before implementation of an effective in-hospital resuscitation system and description of the implementation process. Descriptive statistics were used.

Results: Prior to intervention, defibrillators were unstandardized, misused and often inaccessible. Basic and advanced life support training was suboptimal and poorly overseen. Codes were attended by curious bystanders and inappropriate staff; there was lack of clarity regarding roles and key interventions. A standard defibrillator model was purchased and gradually deployed throughout the hospital; these were configured to meet the unique requirements of each department. Training was restructured. Standard operating procedures were created for all resuscitations while an oversight mechanism was installed. Code teams were created by taking departmental workloads and clinical skills into consideration. A nurse resuscitation coordinator was appointed per department and a hospital-wide culture was fostered where nurses were responsible for the quality of CPR. Major limiting issues such as distrust of device accuracy and safety, knowledge gaps and problems at the device-user interface were identified and bridged.

Conclusions: Creation of an effective in-hospital code system requires thorough research into the culture and requirements of various hospital departments. Multiple barriers must be overcome to set this process into motion.

Relevance to clinical practice: Implementation of change requires more than a declaration from supervisors; it requires deep understanding of the existing culture of different departments to take effective root. Awareness of these often unacknowledged issues combined with the willingness to confront and overcome them are keys to success.

Authors: Sharon Einav, Nechama Kaufman, Joseph Varon

Medication incompatibility in intravenous lines in a Paediatric Intensive Care Unit (PICU) of Indonesian hospital


Objectives: Currently, little is documented concerning the patterns of multiple concurrent medication use utilising single intravenous line. The in-line compatibility issues in Paediatric Intensive Care Units (PICUs) are not as well documented as in adult patients either. This study closely examined the combination of medications used concurrently in a PICU, recorded how medications were used, and then investigated the in-line potential compatibility.

Methods: This study was a mixed model designed first to identify retrospectively the patterns of multiple medication use at any single time of administration (STA). Secondly, a questionnaire was distributed to practitioners to elucidate their perceptions about incompatibility.

Results: From a single lumen peripheral line in-vitro simulation, it was observed that three infusions typically met in sequential Y-sites and had the potential to interact. The combinations identified were morphine+midazolam, midazolam+fentanyl+morphine, morphine+fentanyl+dobutamine, morphine+midazolam+ketamine, and midazolam+dobutamine+norepinephrine. Compatibility data covering simultaneous administration of three-or-more intravenous drugs was not found in 97.5% (n=120) of the cases. Most practitioners (92.9%) recognized incompatibility. Many (46.4%) said they observed >3-10 in-line incompatibilities in a month. Most nurses (78.5%) reported using the manufacturer as their reference source for compatibility data. Flushing with clear fluid between doses was the most used method to prevent incompatibility (45.5%).

Conclusions: It was a common practice to concurrently administer three or more medications: analgesics, sedatives, inotropes, and others, through the same port with major potential for incompatibility issues. Most of the literature is based on two drug comparisons with minimal information on using combinations of three or more. Most practitioners’ understanding of the implications of the terminology of “incompatibility not known or possible” for their patients appeared lacking.

Authors: Suci Hanifah, Patrick Ball, Ross Kennedy

Association of vitamin D plasma concentration with the severity of illness among children with sepsis treated in Pediatric Intensive Care Unit


Objective: To investigate whether vitamin D plasma concentration correlated with the severity of illness in sepsis children treated in a Pediatric Intensive Care Unit (PICU).

Design: This was a cross sectional study.

Settings: Pediatric Intensive Care Unit of Sanglah Hospital Denpasar, Bali, in May to November 2016.

Patients and participants: Samples were patients aged 28 days to 12 years who had sepsis or severe sepsis or septic shock and have been hospitalized in PICU. The subjects who met the inclusion criteria were divided into two groups based on the vitamin D status: normal and insufficient.

Intervention: The severity of illness of the patients in each group was measured using Pediatric Logistic Organ Dysfunction (PELOD) II and Pediatric Risk of Mortality (PRISM) III score. The demographic data, anthropometric status, and severity of the illness were taken from the medical records. The amount of sun exposure and patient nutritional intake were taken from questionnaires answered by the parents.

Results: A total of 48 patients were examined in this study. Bivariate analysis showed that vitamin D insufficiency was associated with a higher severity of sepsis based on the PRISM III (r=-0.44, p=0.006) and PELOD score (r=-0.5, p<0.001).

Conclusion: Vitamin D plasma concentration was negatively correlated with the illness severity in children with sepsis.

Authors: Dyah Kanya Wati, Putu Mas Vina Paramitha Cempaka, I Nyoman Budi Hartawan, Ida Bagus Suparyatha

SARS 15 years on - My reflection on how to motivate your team to overcome the crisis?

Severe acute respiratory syndrome (SARS) was a new infectious disease that emerged in mid-November 2003 in Guangdong, southern China. By the time this global pandemic was declared contained on 5 July 2003 by WHO, it had afflicted 8090 patients in 29 countries.

No other disease had such a phenomenal impact on healthcare workers (HCWs), as they formed about 21% of SARS patients. In Vietnam, Canada and Singapore, the percentages of HCWs were 57%, 43% and 41%, respectively. The SARS crisis had become a medical plague.

Authors: Dessmon YH Tai

Cardiac tamponade in acute necrotising pancreatitis


Objective: This case report highlights cardiac tamponade as a potentially significant complication of severe acute pancreatitis.

Settings: This patient was admitted to the Ng Teng Fong general hospital emergency department. He was subsequently admitted to the Intensive Care Unit (ICU) in the same hospital.

Patients: A 58-year-old male presented with severe acute gallstone pancreatitis with a Glasgow-Imrie criteria of 3. He was admitted for haemodynamic instability and acute respiratory distress syndrome (ARDS). The patient developed new-onset atrial fibrillation, persistent hypotension despite fluid resuscitation and increasing dependence on high inotropic support.

Investigations: A CT abdomen incidentally discovered an accumulation of pericardial fluid. Bedside echocardiography confirmed the presence of a large pericardial effusion consistent with cardiac tamponade. A CT scan revealed severe necrotising pancreatitis with a significant peripancreatic fluid collection.

Interventions: An emergency pericardiocentesis was performed and a pericardial drain was inserted. Eight hundreds ml of haemoserous pericardial fluid was drained over a period of 2 days. The patient’s haemodynamic status improved significantly after drainage of pericardial fluid.

Conclusion: Cardiac tamponade is one of the rare but clinically significant complications of severe acute pancreatitis and should be treated with a high index of suspicion in cases of acute pancreatitis with hypotension.

Authors: Christopher Thong, Jolene Loi, Bryan Chong, Lu Hern Goh

Difference in serum procalcitonin levels between decompensated liver cirrhosis patients with and without bacterial infection


Background: Decompensated liver cirrhosis may increase procalcitonin (PCT) levels in patients without bacterial infection. Previous studies have not provided conclusive results about the difference in serum PCT levels caused by specific liver decompensation and bacterial infection.

Objective: To examine the role of PCT in assisting the diagnosis of bacterial infection in decompensated liver cirrhosis patients.

Methods: A cross-sectional study on decompensated liver cirrhosis patients who were outpatients and admitted to Cipto Mangunkusumo Hospital, Jakarta, was conducted between December 2015 until May 2016. Procalcitonin levels were examined and bacterial infection was identified using standard criteria for each type of infection suspected. Analysis was performed to determine the difference in PCT levels between patients with and without bacterial infection, and to obtain the cutoff point of PCT for bacterial infection diagnosis using the receiver operating characteristic (ROC) curve.

Results: There were 38 patients with decompensated liver cirrhosis, 16 (42.1%) with bacterial infection, and 22 (57.9%) without bacterial infection. Patients with bacterial infection (3.607±0.643 ng/ml) had significantly higher PCT levels than those without bacterial infection (0.738±1.185 ng/ml). The level of PCT for bacterial infection in decompensated liver cirrhosis had an area under the ROC curve of 0.933 (CI 0.853-1.014). The cutoff point of PCT for bacterial infection diagnosis in decompensated liver cirrhosis patients was 2.79 ng/ml, with a sensitivity of 87.5% and specificity of 86.4%.

Conclusion: The PCT levels of decompensated liver cirrhosis patients with bacterial infection were higher than those of patients without bacterial infection. The cutoff point of PCT for bacterial infection diagnosis in decompensated liver cirrhosis patients was 2.79 ng/ml.

Authors: Rino Alvani Gani, Oska Mesanti, Marcellus Simadibrata, Suhendro, Irsan Hasan, Andri Sanityoso, C. Rinaldi, A. Lesmana