Estimates of fluid balance and insensible loss in the critically ill: A cohort study in a non-metropolitan intensive care unit


Assessment of fluid balance has an integral role in management of critically ill patients. Fluid status measurement is multifactorial, comprising of clinical examination, biochemical investigation, and fluid balance records. Error in fluid balance record is well published, as are the adverse outcomes that result from poor fluid control. The current audit was organised to assess the degree of arithmetic error in fluid balance records in Hawke’s Bay Intensive Care Unit (ICU); secondary aims included use and effect of certain diuretic/antidiuretic agents, change in patient fluid status, and change in weight during admission. Twenty ventilated patients admitted to Hawke’s Bay ICU over 14 days (between 1st January 2020 and 24th December 2020) were randomly selected for audit. Twenty-four-hour fluid balance charts were checked, and data regarding secondary outcomes was collected. Seventy point one percent of audited charts were correct, within 0-10 ml from the true fluid balance. Incongruence between change in weight and cumulative fluid balance for 14-day of admission described a 1300 g fluid weight discrepancy, explained by insensible fluid loss.

Authors: Felix Bird, Taylor Campbell, Ross Freebairn

Comparing asynchrony in two noninvasive ventilators


Objectives: Noninvasive ventilation (NIV) is commonly used in respiratory failure as an alternative to more invasive tracheal intubation. A major challenge of NIV is synchronization between the patient’s spontaneous breathing efforts and the support of the ventilator.

Design: We compared simulator-ventilator synchrony characteristics of two ventilators during noninvasive ventilation, using an adult lung simulator under three leak configurations.

Setting: Bench test with lung simulator.

Patients and participants: Active Servo Lung with the bellavista 1000 NIV (bellavista NIV) and Respironics V60 (V60).

Interventions: Three configurations simulating different levels of unintended leak were tested for each ventilator: No Leak, Continuous Leak, and Inspiratory Leak. The recorded pressure and volume waveforms were analyzed to quantify trigger delay, triggering pressure-time product (PTPtrig), pressure-time product at 300 ms (PTP300), insufflation time excess (TI,excess), and time required to reach 63.2% (Texp,63) and 95.0% (Texp,95)of expired tidal volume (VTexp) for each ventilator in all three leak scenarios.

Measurements and results: Trigger delays for the bellavista NIV were significantly lower for all three leak conditions (p<0.0001) and it responded faster to simulated muscle activity compared to the V60. Both the bellavista NIV and V60 experienced no auto-trigger or missed trigger events. The bellavista NIV reached target pressure values more quickly as indicated by significantly higher PTP300 for all three leak conditions (p<0.0001) and had significantly shorter TI,excess (p<0.0001). The bellavista NIV experienced no delayed cycling breaths while more than 25% of V60 breaths showed delayed cycling during inspiratory leak tests.

Conclusions: The bellavista NIV showed significantly lower trigger delays for all three leak conditions, reached target pressure values more quickly (i.e., higher PTP300), and showed superior cycling performance (i.e., lower trigger delay) compared to the V60, which may improve patient-ventilator synchrony and patient comfort.

Authors: Ross C. Freebairn, Andreas D. Waldmann, Christian Remus, Michael J. Pedro

Demographic diversity of COVID-19 patients treated at ICU Special Hospital for Infections Surabaya


Background: The diversity demography of coronavirus disease 2019 (COVID-19) has prompted us to collect data in our workplace. These data are essential because they can serve as a data bank of demographics in one big hospital in East Java. We analyzed patients' characteristics with COVID-19 admitted to the Intensive Care Unit (ICU) Special Hospital for Infections, Airlangga University, Surabaya.

Methods: Retrospective study from medical record of 180 patients with confirmed COVID-19 admitted to the ICU Special Hospital for Infections, Airlangga University of Surabaya between April - September 2020.

Results: Most of the patients were male (67.2%), with median age was 55 (22-83) years. The body mass index (BMI) data consisted of normal (48.9%), overweight (39.4%), obesity class I 7.8%, obesity class II 1.1%, obesity class III 0.6%, and underweight 2.2%. We found severe acute respiratory distress syndrome (ARDS) in 63.9%. The use of invasive mechanical ventilation was 74% of the total patients. Most of the patients (85%) had comorbidity: hypertension, diabetes mellitus, and geriatrics. The average length of stay in the ICU was 8.5 days. We transferred 29% of patients to a low-care ward, and 66.7% died. We identified gastrointestinal symptoms on admission to the ICU were 43.3%, predominantly by nausea and vomiting. Forty-six point seven percent of patients with gastrointestinal symptoms during hospitalization consisted of gastric retention and diarrhea, some with hematin.

Conclusion: The demographic data we present above are limited in our area. The demographic data of COVID-19 patients in other places may be different from the information we obtained. However, data like this may represent the patient's condition in areas similar to ours. Besides, this data can warn that the patient's condition, as in our data, requires special attention. It is necessary to add data from all corners of Indonesia to represent the demographic data of COVID-19 patients in Indonesia.

Authors: Diah Wahyuningsih, Anna Surgean Veterini, Hamzah Hamzah, Lucky Andriyanto

Inferior vena cava collapsibility index pre-induction is superior to caval aortic index pre-induction in predicting hypotension after induction of general anaesthesia


Objective: The study aims to compare the pre-induction inferior vena cava collapsibility index (IVC-CI) and caval aortic index (CAo-I) as hypotension after induction of general anaesthesia (GAIH) predictors.

Design: This is an analytic observational study.

Setting: This study was conducted in Dr. Saiful Anwar General Hospital.

Patients and participant: This study was conducted on thirty-six patients undergoing general anaesthesia.

Intervention: IVC-CI and CAo-I were measured before induction using ultrasound guide. Baseline blood pressure, mean arterial pressure (MAP), heart rate, maximum IVC diameter (dIVCmax), aortic diameter (dAo) were recorded before induction, then were repeated five minutes after induction. Patients received general anaesthesia induction using propofol 2 mg/kg. Analgesic using fentanyl 2 µg/kg and muscle relaxant using atracurium 0.5 mg/kg. Patients received preoxygenation of 100% oxygen for 3-5 minutes.

Result: MAP, heart rate, dIVCmax, dAo before and after induction were significantly different (p=0.000). Thirty patients (36.1%) experienced GAIH. There was no significant difference in age, gender, body mass index, physical status, and MAP pre-induction (p>0.05) between the hypotension and no-hypotension group, except for MAP induction (p=0.001). Pre-induction IVC-CI significantly correlated with hypotension (p=0.024; r=0.375), but not in CAo-I (p>0.05; r=-0.100). The receiver operating characteristic test showed that IVC-CI had higher sensitivity (69.57%), specificity (69.23%), and accuracy (69.44%) than CAo-I, with cut-off value greater than 62.70% (confident interval 95%).

Conclusion: Pre-induction IVC-CI is superior to CAo-I in predict hypotension after induction of general anaesthesia.

Authors: Wiwi Jaya, Ristiawan Muji Lakasono, Alfons Octavian Sabandar, Arie Zainul Fatoni

Early administration of norepinephrine prevents the occurrence of fluid overload in the resuscitation of septic shock patients


Background: Critically ill patients with sepsis usually receive a very large volume of fluids causing a very significant positive fluid balance in an effort to meet the needs of cardiac output, systemic blood pressure, and perfusion to the kidneys. This condition also tends to be associated with poor survival rates. The aim of this study was to determine whether early maintenance of norepinephrine can reduce fluid administration and prevent overload in the resuscitation of patients with septic shock.

Methods: This study was a randomized, non-blind clinical trial, of which the subjects were adult patients with septic shock admitted to the intensive and emergency care unit from January to November 2020. There were two treatment groups of this study, the early norepinephrine group (NEP group) and the 30 ml/kgBW fluid resuscitation one (Fluid group). The test was conducted on the urinary albumin-to-creatinine ratio, increase of serum creatinine value, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio), and intra-abdominal pressure at the time of septic shock diagnosis was established, 3 hours, and 24 hours after the treatment was given. The data was processed using the SPSS device.

Results: Based on the analysis, it was found that there were significant differences in all study variables of the Fluid group compared to the NEP group. The amount of fluid administration in the NEP group averaged 2198.63 ml, less than that in the Fluid group with an average of 3999.30 ml (chi square test p=0.000). By comparing the measurement results to the initial measurement values in the two groups, the fluid overload was high-risk in the Fluid group. There was a significant relationship between the urinary albumin-to-creatinine ratio (OR=48.273; 95% CI=16.708-139.472), the increase in serum creatinine value (OR=73.381; 95% CI=19.955-269.849), the low PaO2/FiO2 ratio (OR=12.225; 95% CI=5.290-28.252), and the increase in intra-abdominal pressure (OR=32.667; 95% CI=10.490-101.724) with the provision of 30 ml/kgBW fluid resuscitation, which indicated the risk of fluid overload.

Conclusion: Early norepinephrine administration can reduce fluid administration and prevent overload in the resuscitation of patients with septic shock.

Authors: Romi Akbar, Yohanes George, Amir S. Madjid, Rudyanto Sedono, Aida Tantri

Comparison of serum tumor necrosis factor, superoxide dismutase, and heat shock protein-70 levels during cardiopulmonary bypass and ischemia reperfusion injury after cardiopulmonary bypass in cardiac surgery


Objective: This study aims to determine the comparison between tumor necrosis factor (TNF)-a, superoxide dismutase (SOD), and heat shock protein (HSP)-70 levels during cardiopulmonary bypass (CPB) and ischemia reperfusion injury after cardiopulmonary bypass.

Design: This study was an analytical observational study with a cross sectional design.

Setting: This study was conducted at Dr. Soetomo General Hospital Surabaya. The period of study was from April 2020 to September 2020.

Patients and participants: Population of study was all adult patients who underwent on pump cardiac surgery. Study samples were patients who were included in inclusion criterion. Patients’ characteristics were presented as frequency and percentage.

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Statistical test using the Wilcoxon signed-ranks test (two-tailed) was performed to determine comparison of TNF-a, SOD, and HSP-70 levels during CPB and after CPB. There were 30 subjects who underwent adult cardiac surgeries including coronary artery bypass graft (CABG), valve, and double procedures. According to statistical test, there was a significant increase of TNF-a, SOD, and HSP-70 levels during cardiopulmonary bypass compared to after cardiopulmonary bypass with p-value <0.05. Pearson correlation test was performed to determine the correlation between elevated levels of TNF-a, SOD, HSP-70 during CPB impact. There was significant correlation between TNF-a and SOD (p<0.05), and also between SOD and HSP-70 (p<0.05).

Conclusion: Our study showed that CPB impact significantly contributes to the increase of TNF-a, SOD, and HSP-70 levels compared to after CPB in patient undergoing on pump cardiac surgeries.

Authors: Teuku Aswin Husain, Setiawan P, Yan Efrata Sembiring, Budiono

Receptor-interacting protein kinase 3 has a good accuracy in predicting mortality of critically septic patients


Objective: Sepsis-related uncontrolled systemic inflammation may trigger necroptosis, which is correlated with receptor-interacting protein kinase 3 (RIPK3) level. A high level of RIPK3 is associated with organ dysfunction and thus, mortality. This study aimed to analyze the ability of RIPK3 level to predict mortality in septic patients.

Design: This was a prospective cohort study.

Setting: This study was conducted in intensive care unit from February until August 2019.

Patients and participants: This study included patients aged 18 years or more who met the Sepsis-3 definition. Baseline demographic data were measured.

Interventions: Blood was collected to measure RIPK3 at sepsis recognition. RIPK3 level was measured using enzyme-linked immunosorbent assay using Bio-Rad (Bio-Rad Laboratories, California, US). Hour-1 bundle resuscitation was performed on all participants. Participants were observed for 28 days for mortality. Data were analyzed using STATA program software.

Measurement and results: A total of 59 subjects were analyzed. The cutoff point of RIPK3 level was 0.51 ng/ml with 92.5% sensitivity and 89.5% specificity in predicting mortality. RIPK3 level has an excellent performance with area under the receiver operating characteristic (ROC) curve (AUC) value of 0.925.

Conclusions: RIPK3 level can be considered a useful tool to recognize high risk mortality among critically septic patients.

Authors: Mayang Indah Lestari, R. Sedono, Zulkifli, IA Liberty

Clinical profile and outcomes in adults with status epilepticus - A prospective observational study


Objectives: Status epilepticus (SE) is a common life-threatening medical emergency, and its neurological outcome requires prompt recognition and management. The present study aimed to determine the clinical profile and outcome of patients with status epilepticus.

Design: Prospective observational study.

Setting: The study was conducted in intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre from March 2018 to September 2019.

Patients and participants: Forty-six status epilepticus patients attending intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre were included and followed for 45 days.

Measurements and results: Baseline data on demographics, comorbidities, duration of each episode, number of episodes, treatment, brain imaging findings (computed tomography [CT] and magnetic resonance imaging [MRI]) and other comorbidities. The collected data was analyzed by analysis of variance (Anova) and independent t-test. P-value <0.05 was considered statistically significant. Out of 45 subjects included in the final analysis, 34 (75.6%) survived, and 11 (24.4%) had died during hospitalization. Mean±standard deviation of age was 43.1±1.02. Thirteen (71.1%) had diabetes mellitus as comorbidity. Twenty-four (53.3%) of them had >15 mins of seizure, 22 (48.9%) were in between 5 to 12 of Glasgow coma scale score. Among the study population, the probable etiology was head trauma 5 patients (11%), viral meningoencephalitis 7 patients (15.6%), acute cardiovascular system 9 patients (24.4%), and alcohol withdraw 14 patients (8.9%). Majority of them (18 patients [40%]) required third-line treatment, 33 patients (73.3%) required in hospital ventilator assistance, and 19 patients (42.2%) developed refractory status epilepticus (RSE). The duration of hospital stay was found to be significant for third-line treatment (21.9 days), mechanical ventilation (21.30 days), and RSE (23.8 days) with a p-value of 0.001.

Conclusion: The duration of hospital stay was significantly associated with the findings on brain MRI, the requirement of in-hospital ventilatory support, the treatment given, and the presence of RSE.

Authors: Aiswarya M. Nair, Priyadarshini Varadaraj, Sivaprakash Varadan, Vaasanthi Rajendran, Viswanathan Pandurangan, K. Madhavan, Anurag P.

Upper airway obstruction due to bilateral laryngeal polyp: A challenge of treatment in rural area


A laryngeal polyp is a common benign lesion of phonotraumatic origins. However, a case of the laryngeal polyp with the upper airway obstruction is rare. The common symptoms include hoarseness or reduced vocal quality, and dyspnea could be present in severe cases. Depending on the anatomical location of the polyp, manipulation on the larynx could cause laryngospasm and life-threatening airway obstruction. In this case, the patient underwent a planned cesarean section under general anesthesia. However, her breathing rhythm did not return spontaneously after surgery and she was sent to the intensive care unit. Bilateral laryngeal polyps were discovered after the removal of an endotracheal tube. However, there was a delay in the removal of the polyps, where it was performed two months after the intensive care unit discharge. The histopathological results confirmed a diagnosis of bilateral angiomatous laryngeal polyps.

Authors: Hamsu Kadriyan, Elya Endriani, Fahrin Ramadhan Andiwijaya, Ida Lestari Harahap

Herpes simplex virus simultaneous encephalitis and liver failure in an immunocompetent adult: A case report


Herpes simplex virus (HSV) are challenging etiologic agents with a wide range of clinical manifestations. We present a case of a 34-year-old immunocompetent male who was brought to the Emergency Department (ED) with fever and prostration. In the first approach, blood tests revealed an acute hepatitis without an identified etiology. Besides the use of N-acetylcysteine, he became worst and evolved to acute liver failure and coma. HSV deoxyribonucleic acid (DNA) was identified in the cerebrospinal fluid (CSF) and blood. Although acyclovir was started on day 3, he developed cardiovascular shock with multiple organ failure and died on the 7th day of hospitalization. A high index of suspicion is needed, and early diagnosis should be promoted between clinicians.

Authors: Tiago Isidoro Duarte, Filipe Damião, Joana Ferrão, Tânia Sequeira, Filipe Sousa Cardoso, Nuno Germano

Sepsis-induced T-cell suppression in pediatric sepsis


Sepsis contributes to significant mortality and morbidity in children. Despite rigorous resuscitation effort, adequate antibiotics and advanced medical support, a significant proportion still face mortality due to multiple organ failure. Recent hypothesis suggests host’s immune response pathology in the form of compensatory anti-inflammatory response syndrome (CARS). This review aims to elucidate the pathophysiology of immune paralysis, both affecting innate and acquired immunity.

Authors: Antonius Hocky Pudjiadi

Position statement for critical care nutrition in Hong Kong


Nutrition therapy is an important yet controversial issue in critical care field. There are numerous international guidelines or publications showing different views; therefore it is difficult to practice critical care nutrition in clinical setting. We believed that by providing appropriate and individualized nutrition therapy, patient’s outcome can be improved.

A local position statement was written by the opinion of critical care physicians, intensivists, and dietitians in Hong Kong after reviewing available evidence; with the aim to provide recommendations in nutrition therapy in local critical care setting and to stress the importance of appropriate nutrition therapy. The position statement includes recommendations on the general aspects, enteral nutrition, parenteral nutrition, and nutrition for specific diseases. A flow chart (Figure 1) is constructed to provide a pathway for implementing nutritional therapy in clinical practice. The position statement was endorsed by the Hong Kong Society of Critical Care Medicine (HKSCCM) and the Hong Kong Society of Parenteral and Enteral Nutrition (HKSPEN).

Authors: Li Li Chang, Yue Ho Vincent Lau, Ting Ting Sinn, Siu Pik Peggy Lee, Ka Ming Kwok, Tin Yan Li, Anfernee Yim

Restrictive versus liberal fluid bolus therapy in septic shock children: An evidence-based case report


Fluid bolus therapy (FBT) is one of prime management in early goal-directed therapy (EGDT) to achieve adequate cardiac output. The Fluid Expansion as Supportive Therapy (FEAST) trial, a randomized-clinical trial that was used as an evidence to support fluid resuscitation recommendation in Surviving Sepsis Campaign (SSC) 2020, must be discontinued because of increasing mortality in the group that received higher volume of FBT. We present a case of a 9-year-old girl, 15 kg, came to emergency ward with refractory septic shock and became fluid overload after the second FBT. This proceeding aimed to deliver evidence-based case practice if the comparison between liberal versus restrictive FBT in children with septic shock.

Authors: Irene Yuniar

Outcomes in severe SARS-CoV-2 patients with liberal oxygenation and steroid therapy - a single centre experience

Real-world reports on outcomes of SARS-CoV-2 infection using higher oxygenation targets along with steroid therapy are lacking. We conducted a retrospective study of patients requiring oxygen support following targets of oxygenation >95% along with steroid therapy. Group 1 with oxygenation through a nasal cannula or Hudson mask, Group 2 oxygenation with venturi system, and Group 3 with high flow nasal oxygen, 35-50 litres; non-invasive ventilation; mechanical ventilation delivering. One hundred and eighteen patients (Group 1 74 patients, Group 2 15 patients, and Group 3 29 patients) were studied. The mean age was 55.7 years and most were male (n=77). One hundred and fourteen received dexamethasone or methylprednisolone. Most (88.3%) had at least one pre-existing chronic medical illness. Overall mortality was 22.8% (n=27). Group 3 had the highest mortality (75.9%) followed by Group 2 (26.7%) and Group 1 (1.35%). Our observation raises the query if a higher target of oxygenation for non-mechanical ventilated patients coupled with steroid therapy is beneficial.

Authors: Priyadarshini Varadaraj, Sowmya Gopalan, Aiswarya M. Nair, Lakshmi Marappa, Vaasanthi Rajendran, Viswanathan Pandurangan, Sudha Madhavan, Rajkumar Mani, Emmanuel Bhaskar

Invasive mechanical ventilation during the first wave of COVID-19: Management and outcomes


Objective: To describe demographics, clinical, and respiratory mechanics (including ventilatory management details) of patients admitted to the Intensive Care Unit (ICU) with severe COVID-19 and to evaluate the effectiveness of gas exchange variables, ventilatory parameters, and ICU illness severity scores in predicting 28-day mortality.

Design: Single-center retrospective cohort study.

Setting: Portuguese medical-surgical ICU.

Patients: Adults sequentially admitted to the ICU, from March 18 to May 12, 2020, with critical COVID-19 requiring invasive mechanical ventilation (IMV) for over 48 hours.

Interventions: None, due to study design.

Measurements and results: Data regarding positioning, positive end-expiratory pressure (PEEP), driving pressure, static lung compliance, and lowest daily arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio throughout the first 5 days of ICU admission were collected from daily ventilatory assessment charts. The median ICU length of stay was 11.3 days and median IMV duration was 9.5 days. The 28-day mortality was 12.1%. When comparing non-survivors and survivors, significant differences were found regarding Simplified Acute Physiology Score (SAPS) II (48.5, IQR 14.0 vs. 32.0, IQR 11.0, p=0.004), PaO2/FiO2 ratio before endotracheal intubation (101.3, IQR 22.5 vs. 174.1, IQR 9.5, p=0.01) and throughout ICU stay. Over 90% of patients were submitted to prone positioning. Use of low PEEP levels and maintenance of low driving pressures in patients whose overall compliance was low as possible.

Conclusions: Significant differences were found regarding SAPS II and PaO2/FiO2 ratios between survivors and non-survivors, eliciting further investigation as potential mortality predictors. With the second wave of the pandemic taking shape, sharing previous experience is crucial to further coordinate efforts internationally.

Authors: Mafalda Aguiar Mourisco, Filipa Resende Brochado, Filipe Silva Machado, Diana Moreira Dias, Ricardo Pinho, Paulo Reis Rodrigues