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

Discovery Kartika Plaza, Kuta, Bali


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.


Editorial Board Member

  • Youzhong An

    People's Hospital, Peking University, Deparment of SICU
    Xi Zhi Men South str, Beijing

  • Simon Nanlohy

    Intensive Care Unit, Mitra Keluarga Kelapa Gading Hospital
    Jakarta, Indonesia

  • Vivi Medina Ginting

    Mitra Keluarga Kelapa Gading Hospital
    Jakarta, Indonesia

  • IH Chaudry

    Department of Surgery
    Brown University and Rhode Island Hospital
    Providence - USA

  • E. Faist

    Department of Surgery
    Ludwig Maximilians University
    Munich - Germany

  • Carole Ichai

    Departement Anesthesie-Reanimation
    CHU NIce Hopital Saint-Roche
    Nice - France

  • T. Kubota

    Department of Intensive and Critical Care Medicine
    Jichi Medical School
    Tochigi - Japan

  • Chae-Man Lim

    Asan Medical Center
    University of Ulsan College of Medicine Poongnap Dong
    Seoul - Korea

  • KS Ng

    Department of Anaesthesia & Surgical Intensive Care
    Changi General Hospital

  • S. McKinley

    Faculty of Nursing, Midwifery and Health
    University Technology Of Sydney
    Sydney - Australia

  • Shin Ok Koh

    Department Anesthesiology, Division Intensive Care Unit
    Yonsei University Medical Center
    Seoul - Korea

  • PJ Papadakos

    Department of Anesthesiology
    Rochester University of Medicine
    Rochester - USA

  • VG Reddy

    Intensive Care Unit, Department of Anesthesia
    College of Medicine Muscat
    Sultanate of Oman

  • Mervyn Singer

    Bloomsbury Institute of Intensive Care Medicine
    Wolfson Institute of Biomedical Research
    London - United Kingdom

  • IKS Tan

    Department of Anesthesia
    Pamela Youde Nethersole Eastern Hospital
    Hong Kong

  • JL Vincent

    Department of Intensive Care
    Erasme University Hospital
    Brussels - Belgium

  • Pravin R. Amin

    Bombay Hospital & Medical Research Centre

  • Luciana B. Sutanto

    Jakarta, Indonesia

  • DB Chalfin

    SICU and Surgical Critical Care
    Beth Israel Medical Center
    New York - USA

  • Noel Cano

    Service Hepato- gastroenterology and Nutrition
    Clinique Residence du Parc
    Marseille - France

  • Robert E. Fromm

    Pulmonary & Critical Care Section
    Baylor College of Medicine, Academic Office, Dorrington
    Houston - USA

  • KM Iqbal

    Department of Anesthesiology
    Institute of Post Graduate Medicine and Research
    Dhaka - Bangladesh

  • YL Kim

    Department of Anesthesiology
    College of Medicine, Seoul National University Hospital
    Seoul - Korea

  • T. Maekawa

    Department of Emergency Medicine and Intensive Care
    Yamaguchi University School of Medicine
    Ube-City - Japan

  • Xian Jun Meng

    Institute of Surgical Research
    General Hospital of Chinese PLA

  • Paul Marik

    University of Pittsburgh Medical School Pittsburgh
    University of Pittsburgh Medical School Pittsburgh
    PA - USA

  • K. Okada

    Department of Anesthesiology
    School of Medicine Teikyo University
    Tokyo - Japan

  • Fang Qiang

    Intensive Care Unit
    First Affiliated Hosptal Zhejiang University
    Hangzhou - China

  • John H. Reeves

    Department of Intensive Care
    Epworth Hospital, Richmond
    Victoria - Australia

  • MM Sayeed

    Burn and Shock Trauma Institute
    Loyola University Medical Center, Illinois, Maywood
    Chicago - USA

  • J. Takala

    Department of Anesthesiology and Intensive Care
    Bern University Hospital
    Bern - Switzerland


Senior Editors

  • E. Benjamin

    Surgical Intensive Care Unit, Department of Surgery
    Mt Sinai School of Medicine
    New York - USA

  • Chen Dechang

    Professor Of Surgery
    Peking Union Medical College Hospital
    Beijing - China

  • PSK Tan

    Department of Anesthesiology
    University of Malaya
    Kuala Lumpur - Malaysia

  • GJ Dobb

    Intensive Care Unit, Royal Perth Hospital School of Medicine and Pharmacology
    University of Western Australia
    Perth, Australia

  • Y. Koh

    College of Medicine, University of Ulsan
    Asan Medical Center
    Seoul - Korea

  • Dessmon YH Tai

    Senior Consultant, Medical Intensive Care Unit, Department of Respiratory Medicine, Tan Tock Seng Hospital, Singapore.
    Senior Clinical Lecturer, Yong Loo Lin School of Medicine, National University of Singapore.


Associate Editors


  • Robert E. Fromm

    Cardiology Section, The Methodist Hospital, Houston, Texas.

  • Paul Marik

    Jefferson University School of Medicine. Philadelphia, USA.

Asia and Pacific

  • Anthony McLean

    Department of Intensive Care. Nepean Hospital, Sydney, Australia.

  • Dessmon YH Tai

    Senior Consultant, Medical Intensive Care Unit, Department of Respiratory Medicine, Tan Tock Seng Hospital, Singapore.
    Senior Clinical Lecturer, Yong Loo Lin School of Medicine, National University of Singapore.

  • Ross Freebairn

    Medical Director, Intensive Care Services, Hawke’s Bay Hospital, Hasting NZ.


  • Santiago Herrero Fernandez

    Department of Intensive Care and Coronary Unit, Hospital de Cabueñes, Gijón, Asturias, Spain

Middle East

  • Mahmoud ElBarbary

    Department of Cardiac Sciencies. King Abdul Aziz Medical City, Riyadh-Saudi Arabia.
    Director of the National and Gulf Center for Evidenced Based Medicine.

  • Abdullah Al-Shimemeri

    Department of Intensive Care. King Fahad National Guard Hospital, Riyadh, Saudi Arabia.



Joseph Varon, MD, FACP, FCCP, FCCM

Chief of Critical Care Services
University General Hospital
Houston, Texas 77030

Clinical Professor of Medicine
The University of Texas Medical Branch, Galveston

Clinical Office:

2219 Dorrington
Houston, Texas 77030
713-669-1671 FAX

Academic Office:

713-839-1467 FAX


About us

Critical Care and Shock has its origin in the regular discussions of a small circle of intensivists from the US, Europe, Japan, and Indonesia who pioneered the international conference of critical care medicine, better known as the Indonesian-International Symposium on Shock and Critical Care, which is held annually in Indonesia since 1994. It was thought at that time that it would be worthwhile to publish a journal in critical care medicine as part of the effort to support and promote the annual conference and to share the latest advances in critical care with the potential readers in Western Pacific region that might complement favorably to the conference.

The first issue of Critical Care and Shock appeared in June 1998 featuring the articles mostly from the guest speakers of the annual Indonesian-International Symposium on Shock and Critical Care.

From its beginning Critical Care and Shock has been the official journal of the Indonesian Society of Critical Care Medicine.

By 1999, at the Council meeting of Western Pacific Association of Critical Care Medicine (WPACCM), it was approved to adopt Critical Care and Shock as the official journal of WPACCM. Also, as of the February issue of 2001, Critical Care and Shock has become the official journal the Philippines Society of Critical Care Medicine.

At present, Critical Care and Shock is enjoying increasing readership in the countries of the Western Pacific region, and welcome the submission of manuscripts from intensivists and other professionals in critical care around the globe to be published in its future issues.