Acute necrotizing pancreatitis associated with Covid-19: A case report


Coronavirus infection is commonly associated with pulmonary manifestations. Extra pulmonary manifestations including gastrointestinal involvement is also well established recently in COVID positive patients. However, pancreatic involvement due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is an unusual presentation and therefore much more attention has to be given to the pancreatic injury caused by SARS-CoV-2 infection. There is different pathophysiology behind the pancreatic dysfunction associated with SARS-CoV-2 infection. It can either be the systematic inflammatory immune response causing tissue damage or direct invasion of pancreatic cells. The virus enters the host cells or tissues via its spike protein that binds to the angiotensin-converting enzyme 2 (ACE2) present in the pancreatic islets cells, which in turn leads to pancreatic injury and dysfunction. It can also occur as an adverse effect of medications like ritonavir-lopinavir that is a therapeutic option for COVID-19 patients. Here, we report a case of a patient with COVID-19-induced acute pancreatitis where medical history and further investigations eliminated all the other expected causes of pancreatitis. He came with complaints of hiccups for two weeks and abdominal pain. He tested positive for COVID-19 and was managed with antibiotics like meropenem. Laboratory investigations as well as computed tomography abdomen paved way for the detection of pancreatic involvement. Pancreatic injury and COVID-19 infection were resolved during the course in hospital and the patient was discharged on medications including zinc, vitamin C supplementation, and also with ciprofloxacin.

Authors: Ameya B., Mahima A., Anju G., Nirmal KP, Uma Devi P., Rajesh G., Priya Nair, Dipu TS, Merlin Moni, Shine S.

Calciphylaxis: A case report and literature review


Necrotising fasciitis is an extremely life-threatening condition, which mainly develop from the necrosis of the subcutaneous fascia and adjacent tissue. It can be caused recurrently from moderate to severe systemic toxicity and be fatal due to lack of medical or surgical treatment. Any absence of particular clinical features can easily result in the under diagnosis such as cellulites or abscess.

The infection can be caused by one or more micro-organisms, both aerobic and anaerobic. Calciphylaxis or calcific uremic arteriolopathy (CUA) is a rare limb threatening condition commonly seen in renal disease patients. It is commonly caused by the accumulation of calcium deposits in the subcutaneous tissue and in the small arteries. Hence, we report a case of 50-year-old female with necrotising fasciitis who was diagnosed with a very rare condition of calciphylaxis.

Authors: Aishwarya Rajeev, Roshni PR

Role of vasopressin in hyponatremic dehydration


Excessive correction of hyponatremia frequently occurs in the management of hyponatremic dehydration. This is more common in infants when correction of dehydration rapidly covers the hyponatremia faster than desired. This is the case of a 2½-month-old male infant with hyponatremic dehydration, which was overcorrected during the initial phase of treatment and was later managed by subcutaneous vasopressin. Vasopressin has got a dual role in the management of hyponatremic dehydration as it helps in dehydration correction as well as slow correction of sodium.

Authors: Anna Kurian, Sruthi G., Sajith Kesavan, Roshni PR

High capillary leak index is associated with increased risk of ICU-related mortality after major abdominal surgery


Objective: Major surgery may induce an inflammatory response, which results in an increased level of C-reactive protein (CRP) and represented in albumin loss to extravascular area due to increased capillary permeability. Our study was to evaluate the association between capillary leak index (CLI) and intensive care unit (ICU)-related mortality in patients underwent major abdominal surgery.

Design: This was a prospective study with cohort analytic design.

Patients and participants: We included adult patients aged 18 and older who were treated in ICU after underwent major abdominal surgery. Patients who were pregnant, having menstruation, relaparotomy, diabetes mellitus, and idiopathic systemic capillary leak syndrome were excluded from this study. Blood was collected before surgery and at 48 and 72 hours after surgery. Patients were observed for mortality incidence during treatment in the unit. The CRP level was measured using ABX Pentra 400 (HORIBA, Germany), whereas the albumin level was measured using HumaStar 80 (HUMAN, Germany). CLI was measured by dividing CRP level by albumin level. Data were analyzed using SPSS Statistics version 21.0 (IBM, New York, U.S.).

Results: CLI at hour 72 was associated with increased risk of ICU-related mortality (RR 21.667; 95% CI 2.938-159.763; p<0.001).

Discussion: Acute inflammation normally resolved within three days. Systematic response to tissue injury, including major surgery, is marked by increased proinflammatory cytokines, which promotes CRP production and capillary leakage. CRP production will increase to its peak level 36-50 hours after inflammation. However, if the injury still exists, inflammatory process will continue.

Conclusions: High CLI at hour 72 can be considered as the risk factor to ICU-related mortality.

Authors: Ade Susanti, Mayang Indah Lestari, Sedono R, Liberty IA

Thromboelastography (TEG) and hemostatic parameters as the diagnostic parameter of septic mortality in the intensive care unit


Objective: This study aimed to determine the relationship between thromboelastography (TEG) and hemostatic parameters and the Sequential Organ Failure Assessment (SOFA) score and mortality of septic patients, and found the potential of those parameters to be the mortality diagnostic parameters.

Design: This was a prospective cohort study.

Setting: This study was conducted in the Intensive Care Unit of Dr. Saiful Anwar General Hospital.

Patients and participant: This study was conducted on thirty septic patients at the Intensive Care Unit.

Measurement and result: Hemostatic parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR]) and thromboelastography parameters (R time, K time, α angle, maximum amplitude [MA], G value, coagulation index [CI], and LY30) were analyzed using the normality test, homogeneity test, t-test, correlation test, and receiver operating characteristic (ROC) curve test in SPSS version 17.0. SOFA scores 8-11 and 12-20 had the highest mortality (100%). R time, K time, CI, α angle, MA, and G value, and all hemostatic parameters significantly correlated with SOFA score (p<0.05). R time, K time, α angle, CI, PT, aPTT, and INR of living patients significantly differed from death patients (p<0.001). K time, α angle, MA, CI, and all hemostatic parameters had an area under the curve (AUC) close to 1 (p<0.05). K time (69.2%) and aPTT (100%) had the highest sensitivity. The positive predictive value (PPV) of all TEG parameters was 100%. aPTT (100%) was the highest in the hemostatic parameters. The hemostatic parameters had a higher sensitivity than its specificity, while the TEG had higher specificity than its sensitivity.

Conclusion: Most thromboelastography parameters and all hemostatic parameters significantly correlated with the SOFA score. K time had the highest sensitivity and specificity as the diagnostic parameter of septic mortality compared to the other thromboelastography parameters, while aPTT was the most sensitive diagnostic parameter of septic mortality compared to other hemostatic parameters.

Authors: Isngadi, Aswoco Andyk Asmoro, Harjuna Atma Wiraharjanegara, Arie Zainul Fatoni

Positive cumulative fluid balance is a risk factor of mortality in critically septic patients


Objective: Excessive fluid administration may increase septic patient mortality. Cumulative fluid balance is an easy, cheap, and non-invasive method of monitoring fluid therapy. Our study aimed to analyze the association between cumulative fluid balance and mortality in critically septic patient.

Design: This was an observational analytic study with a retrospective cohort design.

Setting: This study was conducted in intensive care unit of Mohammad Hoesin Hospital in 2017.

Patients and participants: All adult septic patients from January to December 2017 were included. All patients who did not have completed medical record data were excluded.

Interventions: Data on the mortality and cumulative fluid balance of septic patients were obtained through secondary medical record data and were analyzed using SPSS Statistics version 22.0 (IBM, New York, US).

Measurement and results: Positive cumulative fluid has a very significant association with mortality (relative risk [RR] 3.41; 95% confidence interval [CI] 1.98-5.87; p<0.001). Mean cumulative fluid balance (ml) were greater in non-survivor than survivor group (1937.5±1692.6 vs 877.2±1228). The probability of survival in 28 days was affected by cumulative fluid balance (p=0.001) after being tested with Mantel Haenszel log-rank test. This cumulative fluid balance had a sensitivity of 81.8% and specificity of 89.2% as a predictor of mortality in septic patients.

Conclusions: Positive cumulative fluid balance can be considered as the risk factor to septic patient mortality.

Authors: V. Linardi, SE Handrawan, P. Liana, Mayang Indah Lestari

From the Editors: Introducing our New Website

Dear Readers and Authors,

Critical Care and Shock started as a peer-reviewed journal in 1998 by Dr. Iqbal Mustafa, together with several colleagues, with the specific aim of advancing acute and critical care medicine in the Asia Pacific area as well as other parts of the World due to the increasing popularity of unique therapeutic interventions for critically ill patients.

Unfortunately, Dr. Iqbal Mustafa was unable to continue his mission due to his sudden death on 18 July 2004. We knew he was no longer among us, but his spirit remained among many of his colleagues. Professor Xavier Leverve played an important role in the establishment of Critical Care and Shock and was entrusted to be the Editor-in-Chief replacing Dr. Iqbal Mustafa. In another great loss for humanity, Professor Leverve left us all after 6 years of carrying out his outstanding duties. At that point, Professor Joseph Varon, who had also been involved in this Journal since its founding,  agreed to lead this Journal as Editor-in-Chief and has done so uninterrupted since then.

For over 20 years we have published high-quality peer-reviewed articles in the fields of acute and intensive care medicine. During that period of time, we continue to strive to provide the best academic platform for researchers, educators, and our loyal readers. As the Journal evolved, so did its design. For example, in 2006 we introduced a new color scheme for the Journal with the intention of expressing our desire that the articles submitted bring new and original information of general interest to practitioners dealing with acute and critically ill patients.

We continue to innovate the Journal and its website and try to be at the forefront of scientific publications. Effective December 2021, we are introducing our redesigned website, which we hope can further support our vision and mission in treating acute and critically ill patients around the globe. The website design was created to make access to the Journal easy and the submission process simplified. We realize there are shortcomings here and there, and we appreciate all the input we have received to make this site author- and reader-friendly. We truly hope you enjoy this redesigned website and that you continue to submit your scientific contributions to Critical Care and Shock.

December 2021,

Professor Joseph Varon, MD, FACP, FCCP, FCCM, FRSM                          Simon Nanlohy, MD

Editor-in-Chief                                                                                                 Managing Editor

Authors: Joseph Varon, Simon Nanlohy

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 Laksono, Alfons Octavian Sabandar, Arie Zainul Fatoni

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

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

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

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

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

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.

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