Is hyperchloremia following sepsis resuscitation with 0.9% saline clinically important?

The authors of the article titled “Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: a randomized, double-blind controlled trial”, published in Critical Care and Shock, should be congratulated for design and conduct of a randomized, double-blind clinical trial in severely unwell children with sepsis. The patient population included in the study was severely unwell: all patients enrolled went on to require inotropic therapy, and overall mortality was 24.6%. This stands in contrast to industrialized countries, where inotrope use and death from septic shock are significantly lower. The generalizability of findings between regions...


Authors: Elliot Long, Franz E. Babl, Fran Balamuth, Scott Weiss

Mortality in COVID-19 patients receiving systemic anticoagulant: A systematic review and meta-analysis

Abstract

Background: Coronavirus disease 2019 (COVID-19)/Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is a pandemic disease that quickly spreads throughout the world. There are no definitive therapeutic recommendations that give benefit results until recently. Recent studies suggest that coagulopathy is one of the complications of COVID-19 that increases the mortality rate regardless of the severity. This systematic review and meta-analysis aims to explore the association between systemic anticoagulant use and mortality in COVID-19 patients with various clinical conditions.

Methods: We performed a comprehensive search from several databases. The anticoagulant used in this study comprises of systemic anticoagulants such as low molecular weight heparin (LMWH) or others. The primary outcome was all-cause mortality related to anticoagulant use in COVID-19 patients. The meta-analysis was performed to see the significance of anticoagulants in decreasing the mortality rate of COVID-19 patients.

Results: 7064 patients were analyzed from 7 studies. The meta-analysis showed that systemic anticoagulant use was related with lower mortality rate (RR 0.70 [0.51, 0.97], p<0.03; I2: 87%, p<0.00001). The systematic review reported that 4 of 7 studies favor decreasing the mortality rate in COVID-19 patients administered with systemic anticoagulants.

Conclusion: Systemic use of anticoagulants was associated with a lower mortality rate in COVID-19 patients. Further studies are needed for better causation explanation. The implication of this study is to measure the mortality impact of systemic anticoagulant use in COVID-19 patients.


Authors: Patan Ahmad Setiabudi, Andry Gonius, Thoha Muhajir Albaar, Wella Karolina, Eliana Susilowati, Novi Kurnianingsih

Neutrophil to lymphocyte ratio, monocyte to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume as a predictor of sepsis mortality in children at Dr. Soetomo General Hospital

Abstract

Objective: The purpose of this study was to analyze the neutrophil to lymphocyte ratio (NLR), monocyte to lymphocyte ratio (MLR), platelet to lymphocyte ratio (PLR), mean platelet volume (MPV) as a predictor for mortality in children with sepsis.

Design: This was a prospective cohort study.

Setting: In Pediatric Intensive Care Unit (PICU), Emergency Room, and pediatric ward at Dr. Soetomo General Hospital, Surabaya on March 1, 2020 to August 2020.

Patients and participants: A total of 80 children consisted of 40 septic and 40 non-septic patients were included.

Measurement and results: The leukocyte count in septic patients was not significantly higher than in non-septic patients with a p value>0.05. The number of neutrophils (12.99±7.35x103/mm3 versus 9.12±6.67x103/mm3) had a relevant and significantly higher increase in septic patients (p=0.014). The NLR value (8.99±6.73 versus 4.80±5.30; p=0.001) was higher in septic patients. The cut-off of NLR as a diagnostic marker for sepsis was 3.52 with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and odds ratio (OR) of 82.50%, 47.50%, 61.11%, 73.08%, and 4.26 (p=0.004), respectively. The MLR, PLR, and MPV did not differ significantly between septic and non-septic patients. NLR values (11.61±7.39 versus 5.77±4.05; p=0.014) between survive and dead septic patients. The NLR cut-off 8.98 has sensitivity, specificity, PPV, NPV, and OR of 77.78%, 54.55%, 58.3%, 75%, and 4.20 (p=0.038), respectively, as a predictor for mortality. Patient with NLR more than 8.98 has a risk for mortality 4.20 times higher than those with a low or equal NLR value.

Conclusion: NLR can be used as a predictor of mortality in children with sepsis.


Authors: Frans M. Pasaribu, Arina Setyaningtyas, Mia Ratwita Andarsini

The correlation between vasoactive-inotropic score with mortality and the use of mechanical ventilation in pediatric shock admitted to the PICU in Dr. Soetomo General Hospital, Surabaya

Abstract

Objective: To evaluate and to assess the correlation between the vasoactive-inotropic score (VIS) with mortality and the used of mechanical ventilation in pediatric shock.

Design: A retrospective cross-sectional study.

Setting: The study was conducted in the Pediatric Intensive Care Unit (PICU) at Dr. Soetomo General Hospital, Surabaya from November 1st, 2017 until April 30th, 2018.

Patients and participants: All children <18-year-old with shock who were admitted to the PICU.

Interventions: None.

Measurement and results: Eighty children with shock were admitted in PICU using minimal one vasoactive-inotropic treatment in the first 48 hours were included. Fifty-nine patients were eligible and met the inclusion criteria such as age <18-year-old, has one or more types of shock (hypovolemic shock, cardiogenic shock, obstructive shock, distributive shock), and received at least one vasoactive-inotropic drug £48 hours. We used Chi-square and Fisher’s Exact test and Receiver Operating Characteristic (ROC) curve analysis. The children consisted of 31 males (52.5%) and 28 females (47.5%). The median age was 36 ranging from 2-216 months. Fifty-four used mechanical ventilation. The mean of VIS was 10±6 and the mortality rate was 47.5%. The cut-off value of the ROC curve of VIS in relation to mortality was 6 with sensitivity 82.1% and specificity 64.5%. We divided our subjects into two groups based on the cut-off value of 6 as High VIS (>6) and Low VIS (≤6). The High VIS group consisted of 34 subjects, in which 68% of them died and 59% of them needed mechanical ventilation. VIS had a correlation with mortality (r=-0.472, p<0.001).

Conclusion: VIS had a moderately correlation with mortality, but had no correlation with the used of mechanical ventilation. Nevertheless, VIS may be a better screening tool for pediatric shock in our setting.


Authors: Iin Fatimah, Arina Setyaningtyas, Ira Dharmawati, Abdul Latief Azis, Neurinda Permata Kusumastuti, Dwi Putri Lestari

Effect of zinc supplementation in PELOD-2 score and zinc serum level in children with sepsis

Abstract

Background: Sepsis in children still shows a high mortality rate. Nutritional factors are important in the treatment of sepsis. Zinc is one of the key elements that can limit mitochondrial dysfunction due to an imbalance between reactive oxygen species and antioxidants that occur in sepsis. We aim to determine the effect of Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score and zinc serum level before and after zinc supplementation in septic children.

Methods: This is an experimental study with one group pretest-posttest design in patients aged 1 month to 18 years with sepsis treated at the PICU H. Adam Malik General Hospital from March 2018-February 2019. Oral zinc supplementation was given for 5 days. The PELOD-2 score and zinc serum level measurement were performed by using inductively coupled plasma-mass spectrometry (ICP-MS) on the first and fifth days. Bivariate analysis was performed by paired T test.

Results: A total of 17 patients were analyzed. The paired T test showed significant difference in serum zinc levels before and after supplementation (p<0.001) even though the zinc levels were both still below normal values (28.7±11.7 µg/dl and 40.5±18.3 µg/dl, respectively). PELOD-2 score still showed increasing values with significant differences (p<0.001) before and after zinc supplementation (7.76±2.4 and 11.7±3.3, respectively).

Conclusion: This was the first report that evaluated effect of zinc supplementation on PELOD-2 score. Zinc supplementation did not decrease PELOD-2 score but could give significant improvement in zinc serum level.


Authors: Winny, Munar Lubis, Erna Mutiara

Lower target temperature management in patients with post-cardiac arrest syndrome could not show advantage, with or without resuscitation interval ≤30 minutes. Retrospective analysis of nationwide multicenter observational study in Japan

Abstract

Introduction: Target temperature management (TTM) is one of the effective therapies for patients with post-cardiac arrest syndrome (PCAS). A low target temperature is traditionally believed to be more effective, but this has not been confirmed in recent studies, even in any patient subgroup. Our previous study suggested the possible effectiveness of low TTM for patients with PCAS when the period from collapse to the return of spontaneous circulation (ROSC) is ≤30 minutes. Therefore, we tested this hypothesis in a nationwide Japanese registry.

Methods: This was a retrospective subanalysis based on a registry of patients who experienced out-of-hospital cardiac arrest (OHCA), which was established by the Japanese Association for Acute Medicine. Witnessed cases of adult OHCA were selected. Univariate and multivariate analyses were used to compare the neurological outcomes of patients treated with low (32-33 °C) or mild (34-36 °C) TTM or no temperature management. The analysis was performed in both the total patients and in patients in whom the interval from collapse to ROSC was ≤30 minutes.

Results: We analyzed 1763 cases of PCAS. There was no significant difference in the neurological outcomes of patients treated with low or mild TTM, with or without an interval from collapse to ROSC of 30 minutes. However, neurological outcomes of patients treated with low or mild TTM differed significantly from no temperature management, with or without an interval from collapse to ROSC of ≤30 minutes.

Conclusions: Even in the subgroup in which the interval from collapse to ROSC was ≤30 minutes, neurological outcomes in the low TTM group did not differ significantly from those in the mild TTM group.


Authors: Kazuya Odawara, Tadashi Kaneko, Shunji Kasaoka

The validity of urinary neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker of acute kidney injury in pediatric patients with sepsis

Abstract

Background: Septic patients with acute kidney injury (AKI) are associated with increased morbidity and mortality compared to septic patients without AKI. These usually occur within 24 hours of admission into ICU. The measurement of serum creatinine is usually used to diagnose AKI. However, the concentrations do not change until a decline in kidney function has reached 50% or less within a few days. Many studies have shown urinary neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of AKI with different cut-off points.

Objective: This study aimed to determine the cut-off point of urinary NGAL in predicting the occurrence of AKI in pediatric septic patients within 48 to 72 hours after being admitted into ICU.

Methods: This was an observational analytic study with prospective longitudinal design, carried out on patients who met the inclusion and exclusion criteria at the resuscitation room in the Emergency Room (ER) at Dr. Soetomo Hospital Surabaya. The urine was taken at the 0th, 6th, 12th, and 24th hours for urinary NGAL examination. Every procedure taken on each patient was recorded and followed until the third day to determine factors correlated with AKI.

Result: Of the total 41 pediatric septic patients, 30 met the inclusion and exclusion criteria and about 56.7% had AKI. The urinary NGAL at 0th hour had significant value. A cut-off point of 1242 ng/ml was a better determinant of the incidence of AKI with a sensitivity of 76.5%, specificity of 61.5%, area under the curve (AUC) of 0.715, and relative risk of 2.2. Furthermore, the urinary NGAL at 0th hour was able to differentiate each level of AKI. Yet, the urine values of NGAL at 6th, 12th, and 24th hours were invalid as predictor of AKI.

Conclusion: Urinary NGAL at 0th hour is a valid predictor of occurrence of AKI grades 1, 2, and 3 in pediatric septic patients 48-72 hours after being admitted into the hospital.


Authors: Nugroho Setia Budi, Arie Utariani, Elizeus Hanindito, Bambang Pujo Semedi, Ninik Asmaningsih

The use of point-of-care ultrasound to guide clinical management in intra-abdominal hypertension

Abstract

Introduction: The World Society for the Abdominal Compartment Syndrome (WSACS) developed a medical management algorithm with a stepwise approach to keep intra-abdominal pressure (IAP) £15 mmHg. The role of point-of-care ultrasound (POCUS) as a bedside modality in critical care patients, is not well studied in the intra-abdominal hypertension (IAH) management algorithm.

Aim: To test POCUS in the medical management of patients with IAH.

Method: We conducted a prospective observational study. Those who met the inclusion criteria were assigned to undergo POCUS and small bowel ultrasound as adjuvant tools in their IAH management.

Result: A total of 22 patients met the inclusion criteria and were included in the study. The mean age of the study participants was 65±22.6 years, 61% were men, and the most frequent admission diagnoses were hepatic encephalopathy and massive ascites (5 cases). Ultrasound and abdominal X-rays were comparable in confirming nasogastric tube (NGT)'s correct position, but the ultrasound was superior in determining the gastric content (fluid vs solid) and diagnoses of gastric paresis in 2 cases. Small bowel obstruction was present in four patients and confirmed with computerized tomography (CT) abdomen, and 2 of the patients underwent surgical intervention for mesenteric vessel occlusion and transmesenteric internal hernia. Enema treatment was found to empty the bowel incompletely in 72%, 56%, and 42% of the times on days 1, 2, and 3. Four patients with cirrhosis admitted with upper gastrointestinal bleeding and hepatic encephalopathy (out of a total of 8) were found to have large amounts of ascites and ultrasound (US)-guided paracentesis performed.

Conclusion: POCUS can be used in the nonoperative management of IAH. It is an important tool in the diagnosis and treatment of patients with IAH.


Authors: Zouheir Ibrahim Bitar, Ossama Sajeh Maadarani, Tamer Mohamed Zaalouk, Mohammed Jaber Mohsen, Ragab Desouky Elshabasy, Mahmoud Mostafa Elzoueiry

Pneumomediastinum diagnosed from a remote tele-ICU center?

Abstract

Background: The propagation of remote “telemedicine” has allowed intensivists (and other medical professions) to expand their ability to provide critical care medicine services to intensive care units (ICUs). The physical exam is a pertinent skill that all providers learn early in their medical careers. Key components of the physical exam can help a clinician narrow the differential diagnosis. Even with modern monitoring devices and high-powered imaging, it is hard to replicate the physical exam on a critical care patient from a tele-medicine center.

Case presentation: An experienced intensivist working in a telemedicine (Tele-ICU) center reviewed the daily chest radiograph on a patient with a complex prolonged ICU course. The radiograph was immediately recognized as being concerning for an acute case of pneumomediastinum in a patient with recent tracheostomy manipulation. However, the intensivist was unable to corroborate his suspicions with a good physical exam as the differential diagnosis list was explored.

Conclusions: Acute pneumomediastinum is a severe disease process arising from numerous etiologies that can be life threatening. This disease process can often times be diagnosed from plain chest radiography alone. However remote telemedicine patient care should never supersede a direct bedside physical exam. Every good clinician knows that the fundamental physical exam truly is fundamental.


Authors: Keith Azevedo, Brian T. Wessman

Critical care medicine ocular emergency presentation: Can you see it?

Abstract

Introduction: Ocular emergencies are not a common presentation in the intensive care unit. Intensivists should have a broad differential for the “red eye” and involve ophthalmology appropriately for ocular emergencies.

Background: Ocular emergencies can lead to permanent vision loss if not identified in a timely fashion.

Case description: A patient with hyponatremia and bacteremia admitted to the intensive care unit (ICU) developed an acute painful red eye. Physical exam findings and images are shared.

Conclusion: Due to an acute ocular emergency, this critically-ill patient required transfer to a higher level of care and subspecialty management.

Clinical significance: Education about ocular emergencies is provided for the intensivist; including diagnosis, management, and complications.


Authors: Stephanie Charshafian, Brian T. Wessman

Post-sternotomy mediastinitis: What the intensivist needs to know

Abstract

Deep sternal wound infection (DSWI) is a dreaded complication after cardiac surgery, which dramatically increases health costs, in addition to high morbidity and mortality. The diagnosis and treatment of post-sternotomy mediastinitis (PSM) is a professional challenge. The aim of this current narrative mini review, we will consider epidemiology, implicit risk factors, the basis of diagnosis, preoperative, intraoperative, and postoperative prevention, and antimicrobial procedures, as well as the management of an optimal antimicrobial policy including an antimicrobial switch therapy.

Antibiotic cost represents a significant part of hospital budgets all over the world and more when the cost falls directly on the patient in those health systems that do not cover assistance and treatment. The management of switch therapy is not yet well known in patients with mediastinitis and it is common to find some objection in its use due to the change from long-acting intravenous antimicrobial antibiotics to oral regimen in this type of patients, most of them with high hospitalization rates.


Authors: Santiago Herrero

Correlation between elevated TNF-α, syndecan 1, and urine IL 18 levels in acute kidney injury following on pump cardiac surgery

Abstract

Objective: This study aims to determine the correlation between elevated tumor necrosis factor alpha (TNF-α) and syndecan-1 with urine interleukin (IL)-18 levels as post-cardiac surgery-related acute kidney injury (AKI) marker.

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

Setting: This study was conducted at Dr. Wahidin Sudirohusodo Central General Hospital. The period of study was from October 2019 to February 2020.

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

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Spearman correlation test was performed to determine the correlation between TNF-α, syndecan-1, and IL-18 levels toward AKI incidence. The data was presented with odds ratio (OR) 95% confidence interval (CI). There were 33 subjects who underwent adult cardiac surgeries including coronary artery bypass grafting (CABG), valve, and congenital disorder surgeries. Twenty-one people (63.6%) had AKI and 12 people (36.4%) did not. In AKI patients there was an increased syndecan-1 level of 61.94±36.58 ng/ml with relative risk (RR)=1.11 (95% CI 1.02-1.21), TNF-α level of 6.85±4.05 pg/ml, RR=2.61 (95% CI 1.19-5.71), and IL-18 level of 205.5±121.35 pg/ml, RR=1.38 (95% CI 1.06-1.79). There was a significant correlation between syndecan-1, TNF-α, and IL-18 levels. AKI incidence in post-cardiac surgery patients had a significant elevated IL-18 level (p=0.016), with RR=1.38 (95% CI 1.06-1.79).Conclusion: Elevated syndecan-1, TNF-α, and IL-18 levels were correlated with AKI incidence in post-cardiac surgery patients.


Authors: Andi Adil, Setiawan P, Yan Efrata Sembiring, Budiono

Clinical characteristics and outcomes of critically ill COVID-19 patients admitted to an Infectious Diseases Intensive Care Unit in Portugal

Abstract

Objective: We aimed to describe the characteristics and outcomes of patients with coronavirus disease 2019 (COVID-19) admitted to an intensive care unit (ICU) in Portugal.

Design: This is an observational retrospective study. Demographic and clinical data were collected. Respiratory failure treated with invasive mechanical ventilation (IMV) and death during ICU stay were the main outcomes evaluated.

Setting: This study was conducted in the Infectious Diseases ICU of Centro Hospitalar e Universitário de São João, in Porto, Portugal, between March 11 and August 17, 2020.

Patients and participants: All consecutive patients with confirmed Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, admitted to the ICU during the study period were enrolled, and 62 patients were included.

Measurements and results: The median age was 71 years (IQR, 54-78) and 39 (62.9%) were male. Thirty-four (54.8%) patients received IMV in contrast to 28 (45.2%) who were not intubated and the median lowest PaO2/FiO2 was 86 (IQR, 70-113) in IMV and 150 (94-257) in non-IMV patients. Several patients with severe hypoxemic COVID-19 were treated without IMV, especially with high flow nasal cannula (HFNC). Overall mortality was 21.8% and older age, male sex, active cancer, lower lymphocyte count, higher aspartate aminotransferase (AST) level, and higher creatinine level at admission, hematologic dysfunction, and renal dysfunction during ICU stay were all associated with fatal outcome. Mortality was lower than observed in other series of critically ill patients, although comparisons are limited by different ICU admission criteria, management practices, and duration of follow-up.Conclusions: This study provides data regarding the characteristics and outcomes of COVID-19 critically ill patients that can be used to optimize ICU preparedness in the future.


Authors: António Martins, Margarida Mouro, João Caldas, André Silva-Pinto, Ana Sofia Santos, Sandra Xerinda, Alcina Ferreira, Paulo Figueiredo, António Sarmento, Lurdes Santos

Brain stem infarction as a complication of probable meningitis/encephalitis associated with COVID-19: A case report from Lombok, West Nusa Tenggara

AbstractCoronavirus disease 2019 (COVID-19), firstly discovered in Wuhan, China, has spread globally and was declared by the World Health Organization (WHO) as a pandemic since March 11, 2020. By June 13, 2020, the number of Covid cases in Indonesiawas 37420 with 2091 mortality cases. Lombok is situated in the province of West Nusa Tenggara, currently the number of Covid-19 cases 937. We report a case of probable meningitis/encephalitis associated with COVID-19 with symptoms of fever, headache, and cough. The patient was brought to the Emergency Room with decreased of consciousness, seizures, and neck rigidity. The thoracic examination and head computed tomography (CT) scan revealed pneumonia and brain stem infarction, respectively. Nasopharyngeal swab examination was performed and identified the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ribonucleic acid (RNA) leading to meningitis due to COVID-19.


Authors: Ilsa Hunaifi, Karina Anindita, Elya Endriani, Sri Kartika Sari, Ririn Setyawati, Indah Widya Astuti, Sandra Yuliana Andini Putri, Zainul Muttaqin

A case report: Does amynophilline have opportunity in COVID-19 management?

AbstractThe novel coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2), which causes severe acute respiratory distress syndrome (ARDS). ARDS causes the patient to have difficulty breathing, the appearance of pneumonia from chest radiological images, and from the examination results by pulse oximetry, the picture of oxygenation is poor. Most clinical complaints require mechanical ventilation and treatment in the intensive care unit (ICU). We made several attempts to increase oxygenation and ventilation from a pharmacological and non-pharmacological perspective. From pharmacology, given drugs that help from an immunological aspect, reduce preload, help cardiac contractility, and anti-virus. In this case report, we report aminophylline administration as a therapeutic modality in critically ill patients' handling due to COVID-19.


Authors: Anna Surgean Veterini, Lucky Andriyanto, Hamzah