Diagnosis and treatment of infective endocarditis in intensive care


Infective endocarditis (IE) is an infectious microbial disease of the heart valvular endothelium. The characteristic lesion consists of the presence of vegetations that can settle in the valvular veils, tendon cords or mural endocardium.

Hospital mortality in patients with severe sepsis or septic shock has been between 20 and 50%, a fact probably underestimated and overshadowed by a late referral to the intensive care unit, even though clear criteria for entry into the unit have been established for patients with this situation.

The objective of this study was to know the characteristics, evolution and prognosis of patients with infective endocarditis who required treatment in the Intensive Care Unit.

Authors: Jesús Cobo Molinos

Comparative analysis of clinical pharmacy interventions in a pediatric intensive care unit


Objective: The objectives of this study were 1) to describe and characterize interventions performed by a clinical pharmacist and 2) provide a comparative analysis of length of stay, mortality, and drug charges in control and intervention groups.

Design: This was a retrospective analysis of clinical pharmacy interventions performed in a Pediatric Intensive Care Unit (PICU) over two years. The clinical pharmacy faculty member was a dual-residency trained specialist in pediatric critical care, and was on-site in the PICU for approximately 0.5 full time equivalents.

Setting and patients: The interventions occurred in an 18-bed medical-surgical PICU in a tertiary care children's hospital. All patients admitted to the PICU during the study period were included.

Interventions: The intervention group was comprised of patients admitted to the PICU during the study period for which the clinical pharmacist suggested changes in medication therapy. All other PICU patients were included in the control group. Interventions suggested were varied, including drug dosing adjustments, antibiotic recommendations, sedation recommendations, and discontinuation of drug therapy.

Measurements and main results: On average, there were 4.4 interventions per patient (0.35 interventions per patient-day). Dosing recommendations, pharmacokinetic recommendations, and discontinuation of medications were the most common types of interventions performed. Antibiotics and sedation/analgesia were the most common drug classes for intervention. There were statistically significant differences in the length of stay and mortality of groups, with both higher in the intervention group. Notably, the intervention group also had higher Pediatric Risk of Mortality (PRISM) scores and drug charges, signifying increased severity of illness compared to the control group. Estimated annual cost savings in the intervention group was $ 86,000.

Conclusions: Antibiotics and sedation/analgesia dosing were the most common areas for pharmacy interventions. Patients with higher PRISM scores had increased interventions. Cost savings were considerable even with a part time pharmacist.

Authors: Joseph M. LaRochelle, Kayrah Jack, Brent A. Kitto, Aryn Karpinski, Amy M. Creel

The effect of mild hypothermia therapy in the level of MMP-9 protein and the Marshall CT score in high risk traumatic brain injury


The effect of mild hypothermia therapy (34°-36°C) and alterations of matrix metalloproteinase-9 (MMP-9) were examined in 20 patients with high risk traumatic brain injury (TBI). The neurologic status was assessed using the Full Outline of UnResponsiveness (FOUR) score and the outcome using the Marshall CT score. The objective of this study was to determine serum MMP-9 level and the Marshall CT score. This research used a prospective randomized controlled study and was conducted in RD Kandou Hospital Manado. Patients with high risk TBI (the FOUR score ≤7) were randomized into two groups, with and without mild hypothermia therapy, and were investigated within 24 and 72 hours. The MMP-9 protein levels were estimated using enzyme-linked immunosorbent assay (ELISA). Different levels of these variables were compared in the two groups. The results showed that the level of MMP-9 protein significantly decreased (p<0.05) in the hypothermia group; however, there was no significant improvement of the Marshall CT score (p>0.05) within 24-72 hours. The study concluded that mild hypothermia therapy had a significant influence on the alteration of biomarkers rather than the alteration of anatomical imaging in high risk TBI patients.

Authors: Eko Prasetyo, Andi Asadul Islam, Mochammad Hatta, Djoko Widodo, Ilhamjaya Pattelongi

Use of levocarnitine as an alternative treatment for non-anticoagulant rodenticide poisoning


The objective of this text is to inform and motivate further investigation about the use of levocarnitine as an alternative antidote in patients poisoned by non-anticoagulant rodenticides in a kind of retrospective study through the report of 3 serial cases presented in the Intensive Care Unit (ICU) of the General Hospital Zacatecas 'Luz González Cosío', in Zacatecas, Mexico. Two of them were intoxicated with zinc phosphide and one with sodium fluoracetate, all with similar signs and symptoms. In addition to having received vital support measures in the ICU, levocarnitine was administered intravenously, with remission of symptoms in the short term and hospital discharge without apparent sequelae. Therefore, it is appropriate to consider future research on the use of levocarnitine in this kind of patients, in addition to vital support measures.

Authors: Omar Alberto Venegas Gurrola, Mónica Rodríguez Borroel, Omar Uriel Sánchez Alba, César Fabián Díaz García

Methaemoglobinaemia-induced oxygen desaturation complicating chest trauma

Case presentation

A 72-year-old man presented to the Emergency Department by ambulance following a rollover motor vehicle crash preceded by black-out symptoms. He had been suffering from dermatitis herpetiformis for the last six years and was being treated with dapsone 100 mg and a partially gluten-free diet. On admission he had a respiratory rate of 22, pulse oximetry saturations of 89% improving to 93% with 3 l/min via nasal prongs, a heart rate of 75 bpm, and a non-invasive blood pressure of 111/52. No life-threatening injuries were identified on primary or secondary survey. A trauma CT-series noted left sided rib fractures.

Authors: Ravi Mistry, Ross Freebairn

Propofol-induced macroglossia: a case report


A 78-year-old lady, without prior exposure to propofol, was admitted to the hospital due to recurrent seizures, and respiratory arrest, which required intubation in order to secure her airway. Propofol was used as the initial sedative agent. Two weeks later she required again administration of propofol, time at which she developed acute macroglossia. This subsided after weaning off the propofol. When she was cared by another team and received for the third time propofol, she developed macroglossia again, and similarly subsided when propofol was weaned off. Allergic reactions to propofol are well documented. We believe that an allergic reaction occurred upon the second and third administration of propofol in our patient.

Authors: Abbas Alshami, Johanan Luna, Joseph Varon

Decision making of tracheostomy and extubation outcomes in mechanically ventilated patients evaluated by logistic regression and decision tree analyses


Background: Most studies determining the predictors of extubation outcomes in patients with mechanical ventilation have not included high-risk populations who avoid extubation and undergo tracheostomy.

Objective: To evaluate predictors of extubation intolerance by analyzing patients regardless of whether extubation was attempted or not.

Design: Retrospective cohort study.

Settings: Mixed intensive care unit (ICU) of Kumamoto University Hospital.

Patients and participants: Medical data of 288 consecutive mechanically ventilated adults were collected. Initial outcomes of endotracheal tube treatment were classified as 1) successful extubation, 2) extubation failure, and 3) tracheostomy without attempting extubation. Clinical variables responsible for those outcomes were determined by logistic regression and decision tree analyses. We defined combined outcome of extubation failure and tracheostomy as extubation intolerance in the present study.

Results: Of 288 patients, 17 failed extubation and 37 opted for tracheostomy without extubation. Logistic regression analysis revealed that the significant predictors of extubation failure were weak cough strength, poor consciousness, and excessive airway secretion. The propensity score of extubation failure calculated by logistic regression analysis in the tracheostomy group was as high as that of extubation failure group. A decision tree to predict the outcomes was described by branching with consciousness, style of ICU admission, and volume of airway secretion.

Conclusions: The principle predictors of extubation intolerance were related to instability of airway patency, and the decision making of tracheostomy was shown to be appropriate. These statistical methods could reduce the selection bias of study subjects.

Authors: Susumu Hirosako, Hirotsugu Kohrogi, Katsuyuki Sagishima, Keisuke Sakai, Yohei Migiyama, Hidenobu Kamohara, Hiroaki Kawano, Yoshihiro Kinoshita

Malignant pericardial effusion presenting as a wheeze- case report


Slow growing pericardial effusion is detected less commonly than acute pericardial tamponade. However, it is equally life threatening if it is more than 250 to 300 ml and can contribute to a similar picture of a fix cardiac output obstructive shock. We would like to report a case of malignant pericardial effusion that was detected in the ICU when the patient presented to the hospital with shortness of breath and generalized wheezes suggestive of respiratory failure from chronic obstructive lung disease (COPD).

Authors: Eng Kiang Lee

Case report: central venous pressure-guided de-resuscitation in sepsis patients with fluid overload induced acute kidney injury


Background: Aggressive fluid resuscitation is commonly administered in septic patients as recommended by Surviving Sepsis Campaign. However, positive fluid cumulative balance resulting in fluid overload is correlated with various complications such as acute kidney injury, acute respiratory distress and delayed wound healing.

Case report: This report presents four septic patients with fluid overload and acute kidney injury who underwent active de-resuscitation aiming central venous pressure between zero and two mmHg.

Discussion: In all patients, central venous pressure guided de-resuscitation was associated with systemic oxygenation improvement (arterial lactate dropped from 8.3 to 0.8 mmol/l, from 5.3 to 0.3 mmol/l, from 3.5 to 0.5 mmol/l, and from 3.3 to 0.7 mmol/l) and acute kidney injury resolution without hemodynamic instability and elevated lactate level. Negative cumulative balance is associated with a significant reduction of norepinephrine dose.

Conclusion: A de-resuscitation strategy based on the target of central venous pressure 0-2 mmHg is a safe and effective procedure that resulted in improvement in hemodynamics, serum lactate, renal function and also systemic oxygenation.

Authors: Ni Luh Kusuma Dewi, Yohanes WH George

Status epilepticus caused by cerebral venous thrombosis in the puerperal period: case report and literature review


Status epilepticus (SE) caused by cerebral venous thrombosis (CVT) is rare in pregnancy and puerperium, with few cases described in literature. Seizures in pregnancy are usually due to previous epilepsy or pregnancy related disease, such as eclampsia, posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), eclampsia and thrombotic thrombocytopenic purpura (TTP). Due to its high mortality, the SE and the underlying disease must be promptly managed. In this article, we present a case of SE in postpartum due to cerebral venous thrombosis and we reviewed the cases described on the topic.

Authors: Orivaldo Alves Barbosa, João Filho Araujo Ribeiro, Paola Lima Lemos

Role of hemofilter with endotoxin adsorption capacity in management of septic shock


We reported an adolescent male with acute lymphoblastic leukemia who developed septic shock due to Klebsiella pneumoniae. Continuous renal replacement therapy using a hemofilter with endotoxin adsorption capacity was used to remove endotoxin and cytokines. The promising result suggested that this technique may be applied as an adjuvant therapy for treatment of septic shock.

Authors: Wun Fung Hui, Winnie Kwai Yu Chan

We remember with love and joy Mahmoud Elbarbary, MD, PhD, MSc, EDIC (1959-2017)

Mahmoud left us on May 8th after a brief illness while in Riyadh Saudi Arabia, but what he left behind was an amazing legacy of service.


Incidence of CAUTI in a new integrated ICU/HD in Singapore over 1 year


Hospital-acquired infection worldwide has been associated with significant mortality and morbidity and unfortunately catheter-associated urinary tract infection (CAUTI) is known to be one of the commonest hospital-acquired infections.

A retrospective study was done to determine the incidence of CAUTI in the Intensive Care Unit/High Dependency (ICU/HD) in Ng Teng Fong General Hospital (NTFGH) since it was opened from 1 July 2015 to 31 July 2016. NTFGH Intensive Care Unit is an integrated ICU/HD unit that manages a combination of surgical, medical, trauma and cardiac patients. The inclusion criteria were patients catheterized and with urinary tract infections diagnosed in ICU/HD and also diagnosed with UTI within 48 hours of discharge from ICU/HD. The data was retrieved from hospital electronic database. The types of organisms and their resistant pattern to antibiotics were analysed.

A total of 3159 patients were admitted to the ICU/HD during this period. One hundred eighteen patients were diagnosed with urinary tract infections in general and out of this group 69 patients were noted to have CAUTI based on CDC criteria. The commonest organisms related to CAUTI were Escherichia coli and Klebsiella pneumoniae. These two organisms showed a similar pattern of establishing resistance to all the first line antibiotics used and they were ampicillin, amoxicillin-clavulanic acid and cephalosporins. Though the usage of quinolones, sulfamethoxazole-trimethoprim and gentamicin were low, these organisms have also established resistance to these 3 antibiotics. Enterococcus fecalis was the next commonest organism and was often associated with the presentation of diarrhea. Other organisms including Pseudomonas, Proteus, Enterobacter, Morganella, Citrobacter, Burkholderia and Staphylococcus were sporadically reported.

The common risk factors for developing CAUTI noted were surgical elderly male patients with diabetes and a history of obstructive UTI.

A committee involving a team from ICU has been set to review the current indwelling urinary catheter bundle and rectify the problems and implement new measures to reduce the incidence of CAUTI.


A randomized pilot study of parenteral glutamine supplementation in severe sepsis


Purpose: Glutamine depletion can occur in critically ill patients and parenteral glutamine supplementation can have beneficial effects on critically ill patients by preserving gut barrier and improving immune function. We wanted to examine the effect of glutamine supplementation in a cohort of severe sepsis patients admitted to a hospital in South East Asia.

Design: A single center, randomized, doubleblinded, placebo-controlled, pilot study. The primary outcome was 28-day mortality. Secondary outcomes were ICU length of stay (LOS), hospital LOS, duration of mechanical ventilation and occurrence of new infections. Disease severity on admission was assessed by Sequential Organ Failure Assessment (SOFA) score.

Setting: Medical intensive care unit (MICU) of Changi General Hospital, which is a 1000-bedded teaching hospital in Singapore.

Patients and participants: Patients admitted to the MICU for severe sepsis with ≥2-organ dysfunction.

Interventions: In the intervention arm, intravenous glutamine was given for 5 days at a dose of 0.5 g/kg body weight/day. The placebo was normal saline.

Measurements and results: Thirty-nine patients were randomized to receive glutamine (n=19) or placebo (n=20). The glutamine group exhibited milder disease severity than placebo (median SOFA score 8 vs 11, p=0.038). There was no overall difference in 28-day mortality between the glutamine and placebo (42% vs 15%, p=0.06). When adjusted for disease severity, the glutamine arm had 5.6 times higher death rates (95% CI 1.1-30.2, p=0.044). The glutamine group had lower incidence of new infections (0% vs 30%, p=0.02). There was no difference in ICU LOS, hospital LOS and the duration of mechanical ventilation.

Conclusions: Parenteral glutamine may increase mortality risk in ICU patients with severe sepsis while reducing the risk of new infections.


A comparison of NSS vs balanced salt solution as a fluid resuscitation and impact of fluid balance on clinical outcomes in pediatric septic shock


Septic shock is a common condition affecting children worldwide. Initial resuscitation with crystalloid fluid is the first step in treatment of septic shock. However, there is increasing concern about side effects of using normal saline. Our objective was to compare the effectiveness of balanced salt solution vs 0.9% normal saline solution (NSS) on decreasing morbidity and mortality in pediatric septic shock. This was a prospective observational study enrolled septic children aged 1-15 years treated at the Department of Pediatrics, King Chulalongkorn Memorial Hospital. They were given fluids resuscitation according to Surviving Sepsis Campaign (SSC) guidelines. Thirty-five sepsis children were enrolled, 20 received normal saline as first line fluid resuscitation and 15 received balanced salt solution (Ringer lactate solution [RLS]) as first line fluid resuscitation. Baseline characteristic of both groups were similar. RLS group received significantly less fluid resuscitation at 24 and 48 hours compared to NSS group (134.3±42.9 vs 171.3±49.5; p=0.02, 236.9±75.7 vs 313.1±115.3; p=0.03). Moreover, RLS group had significantly less metabolic acidosis and better base excess at 6 hours and 24 hours compared to NSS group (2.5±4.1 vs -3.7±4.1; p<0.001, 3.4±3.2 vs -1.2±3.9; p=0.03). There was no statistically significant difference in mortality between two groups (15% [n=3] NSS, 6.7% [n=1] RLS).

Conclusion: Using balanced salt solution for resuscitation decreased metabolic acidosis and tended to decrease fluid intake and fluid accumulation.