Resuscitation incoherence after cardiac arrest due to acute intraoperative pulmonary emboli related acute right heart failure: A case report


Resuscitation incoherence is a mismatch between macrocirculation, microcirculation, and cellular parameters after resuscitation. We report a 34-year-old obese male patient, suffering from end-stage renal disease or chronic kidney disease (CKD), underwent routine hemodialysis three times a week and hypercoagulability state with rivaroxaban therapy. He had a cardiac arrest during kidney transplant surgery. Acute right heart failure causing cardiac arrest was presumably caused by acute intraoperative pulmonary embolism. Hemodynamic and resuscitation incoherence occurred and proper treatment was needed. At the time of cardiac arrest, hemodynamic coherence was lost and resuscitation was performed to restore this loss by correcting the possible causes of cardiac arrest. Although the return of spontaneous circulation (ROSC) was successfully achieved, a type 1 resuscitation incoherence occurred where the macrocirculation was optimal but cellular parameters were disturbed by cell hypoxia, characterized by high levels of lactate. Type 2 resuscitation incoherence was also found in this patient until the end of treatment in the intensive care unit (ICU). Cellular parameters such as lactate levels and the venoarterial carbon dioxide tension difference to arteriovenous oxygen content difference ratio (P[v-a]CO2)/(C[a-v]O2) continued to improve during ICU treatment, but cell hypoxia might occur since the central venous pressure (CVP) value as a macrocirculation parameter was likely to increase, presumed to be caused by incomplete resolved acute pulmonary embolism related chronic thromboembolic pulmonary hypertension.

Authors: Ade Susanti, Mayang Indah Lestari, Dita Aditianingsih

Are preinjury anticoagulant and antiplatelet medications a pitfall in the bleeding tendencies of elderly trauma patients in intensive care?


Purpose: The elderly are more likely to be on anticoagulant or antiplatelet medications, which increase bleeding. We aimed to determine the effect of preinjury anticoagulant or antiplatelet medications on required blood transfusions and the trauma outcomes of elderly patients.

Methods: We retrospectively reviewed the medical records of all elderly trauma patients admitted to Chungbuk National University Hospital from January 2016 to June 2019. We compared the required number of blood transfusion units, complications, and mortality rate between those on anticoagulant or antiplatelet medications and those that were not, using the chi-squared test, independent t-test, linear regression analysis, and logistic regression analysis.

Results: Out of 466 patients, 142 were on anticoagulant or antiplatelet medications while 324 were not. There was a significant statistical difference in the unit amount of red blood cells transfused within 4 hours of arriving at the hospital between the medicated and non-medicated groups (0.89 vs 1.43 units, respectively, p=0.02); however, multivariate analysis showed no statistical difference (p=0.28). The medication group showed a higher rate of complications compared to the non-medicated group (47.9% vs 29.6%, respectively, p=0.001), bleeding (17.6% vs 2.8%, respectively, p=0.001), and pneumonia (24.4% vs 14.2%, respectively, p=0.01). There was no statistical difference in the mortality rate (16.9% vs 22.2%, respectively, p=0.21).

Conclusion: Preinjury anticoagulant or antiplatelet medications in elderly trauma patients increased bleeding and complications such as pneumonia but did not affect transfusion requirement, or mortality rate.

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Joong Suck Kim

Does preinjury anticoagulant or antiplatelet medication increase the need for blood transfusions in patients aged older than 65 years with traumatic brain injury?


Background: Anticoagulant or antiplatelet medications are commonly prescribed in older adults, increasing bleeding tendency and affecting traumatic brain injury (TBI)-related morbidity and mortality.

Objectives: This study aimed to determine the effects of preinjury anticoagulant or antiplatelet medication on blood transfusions and outcomes in patients aged >65 years with TBI.

Methods: We retrospectively reviewed records of patients with TBI without other injuries admitted to our hospital between January 2016 and June 2019. We compared the number of blood transfusions administered and outcomes between patients who were receiving anticoagulant/antiplatelet medication and those who were not.

Results: Overall, 82 patients (66% male) with an average±standard deviation age of 76.6±7.29 years were enrolled. Thirty-one patients were receiving anticoagulants or antiplatelets and 51 were not. There were no differences in age, medical history, Injury Severity Score, and Glasgow Coma Scale score between the groups. International normalized ratios of patients who were on warfarin were significantly higher than those of patients who were not (p<0.05). Analysis of covariance demonstrated that patients who were receiving medications needed more plasma transfusions than did those who were not (p<0.05). The incidence of complications was 64.5% and 37.3% in patients who were and were not receiving medication, respectively (p<0.05). Multivariate regression analysis showed that patients who were receiving medications bled 5.62 times more than did those who were not (95% confidence interval: 1.52~20.70).

Conclusions: Bleeding incidence and plasma transfusion requirements are increased by preinjury anticoagulant or antiplatelet medication in patients aged >65 years with TBI.

Authors: Se Heon Kim, Young Hoon Sul, Jin Young Lee, Jin Bong Ye, Jin Suk Lee, Hong Rye Kim, Soo Young Yoon, Joong Suck Kim, Moon Sang Ahn

Future views on nanonutrition for critically ill patients: The role of extra virgin olive oil nanoemulsion in sepsis enteral nutrition


Enteral nutrition (EN) can maintain the structure and function of the gastrointestinal mucosa better than parenteral nutrition. Early intervention by enteral nutrition in critically ill patient may help the patient from fatality of multiple organ failure. Oral nutrition is an attempt to provide a physiological nutrition that is expected to trigger the immune system, prevent blood stream infection from the intravenous route, and reduce cost of therapy. One of the problems that inhibits supply of enteral nutrition in critically ill patients is absorption disorders that cause the body’s nutritional needs to be hampered. Administration of extra virgin olive oil (EVOO) in the form of nanoemulsion is expected to improve pharmacokinetics and pharmacodynamics in those patients. EVOO is one functional food that has a lot of health benefits. Nanoemulsion-based delivery systems are proven to increase utilization of lipophilic bioactive components in food, personal care, cosmetic, and pharmaceutical applications. So far, there is no report describes the use of enteral nanonutrition in critically ill patients. This review discusses the perspective view of using EVOO nanoemulsion to care the critically ill patients.

Authors: Anna Surgean Veterini, Subijanto Marto Soedarmo, Hasanul, Annis Catur Adi, Heni Rachmawati, Nancy Margarita Rehatta

Giant extrathoracic hematoma in a COVID-19 patient

Case presentation

A 69-year-old lady presented to our emergency department with a two week history of shortness of breath, fever, and dry cough. Chest computed tomography revealed patchy ground glass opacities throughout both lungs, most pronounced in the mid-to-lower lung zones bilaterally, with peripheral distribution. She was admitted to the hospital with the presumptive diagnosis of coronavirus disease 2019 (COVID-19) pneumonia. She received our standard MATH+ protocol (hydroxychloroquine, intravenous ascorbic acid, zinc, thiamine, melatonin, azithromycin, vitamin D3, and enoxaparin). This was followed by oral anticoagulation with warfarin. On day 18, she complained of severe right breast pain. Upon examination she...

Authors: Elizabeth Gamboa, Joseph C Gathe Jr, Joseph Varon

Acute necrotizing encephalopathy secondary to COVID-19

A 54-year-old gentleman without significant past medical history presented to our emergency department with complaints of shortness of breath and fever. On arrival he was very disoriented, and unable to communicate well. He was found to be positive for SARS-CoV-2 and had severe pneumonia. On hospital day 8, he abruptly began to decline, initially presenting with elevation in blood pressure, and soon thereafter with severely decreased level of consciousness. This was followed by a cardiac arrest, that was treated, and he had eventual return of spontaneous circulation within 15 minutes. Despite this, the patient never regained consciousness. A head computed...

Authors: Swethen Dushianthan, Elizabeth Gamboa, Joseph Varon

Acute ischemic stroke - an extrapulmonary COVID-19 presentation


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that causes coronavirus disease 2019 (COVID-19) has emerged as a high contagious and deadly virus, with an endless capacity to surprise clinicians with new presentations and complications. Although COVID-19 typically presents as respiratory infection but it can present with thromboembolic event. Our hospital, one of the main territory care hospitals in Kuwait, experiencing sudden surge of stroke cases in last few weeks of COVID-19 pandemic. Stroke is a medical emergency which needs early recognition and management for better neurological outcome. In the COVID-19 pandemic, when seeing patients with neurological manifestations, clinicians should consider COVID-19 as a differential diagnosis and should take full protective measures until proven to be negative. Based on our experience, we want to highlight that COVID-19 patients can present with extrapulmonary manifestation like stroke. Emergency physicians, stroke team and intensivist should be wary of this fact. Triaging and COVID-19 screening is the key to minimize the virus spread and to ensure staff and other patients safety.

Authors: Beena Yousuf, Abdalaziz HRH Gh S. Alsarraf, Huda Alfoudri

Renal angina index in pediatric septic patients as a predictor of acute kidney injury in remote area


Background: One of the most common sepsis comorbidities is severe acute kidney injury (AKI), which occurs in about 20% of pediatric patients with severe sepsis and is independently associated with poor outcomes. Many studies have shown the ability of renal angina index (RAI) with a cut-off point of 8 to predict the risk of AKI grade 2 and 3, but with varying sensitivity and specificity. Therefore, this study aims to identify a RAI cut-off point to predict the incidence of AKI in pediatric septic patients in the setting of a regional hospital in Indonesia.

Methods: An observational analytic study with a prospective longitudinal design was conducted on 30 pediatric patients in the Resuscitation Room of Dr. Soetomo General Hospital Surabaya. Patients who met the inclusion criteria were given 1-hour standardized resuscitation, then were observed. Every action taken to the patient was recorded, fluid input and output were measured, and mechanical ventilation and vasopressor administration were documented until the third day to determine factors influencing the incidence of AKI.

Results: In this study, 56.7% of pediatric septic patients had AKI. The Pediatric Logistic Organ Dysfunction-2 (PELOD-2) score in this study had a median of 11, in accordance with the pediatric sepsis guideline. RAI, with a cut-off point of 8 as a predictor for AKI grade 2-3, had a sensitivity of 100% and a specificity of 68% (area under the curve [AUC]=0.912). In terms of AKI risk tranche, the majority of patients (93.1%) had mechanical ventilation, while in terms of AKI injury tranche, the majority met the fluid overload criteria (79.3%).

Conclusion: RAI, with a cut-off point of 8, can be used as a predictor for severe AKI in pediatric septic patients.

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

Balanced salt solution versus normal saline solution as initial fluid resuscitation in pediatric septic shock: A randomized, double-blind controlled trial


Objective: Initial fluid resuscitation is mandatory in treatment of septic shock. Current sepsis guidelines do not have the recommendation for either balanced salt or normal saline solution for initial fluid resuscitation. The objective of this study was to determine the impact of balanced salt solution (BS) versus normal saline solution (NS) in pediatric septic shock as initial fluid resuscitation.

Design: A double-blind randomized controlled trial study.

Setting: A single tertiary care center in Bangkok, Thailand.

Patients and participants: Children aged 1 month to 18 years who were diagnosed with septic shock. We excluded patients who received fluid resuscitation in the 24 hours prior to septic shock, end-stage disease, and refusal of informed consent.

Interventions: Patients were randomly assigned into 2 groups after being diagnosed with septic shock and required fluid resuscitation (NS or BS).

Measurements and results: Demographic data, vasoactive-inotropic scores, and outcomes were evaluated. The primary outcome was incidence of hyperchloremic metabolic acidosis. Sixty-one septic shock children were enrolled into this study (NS=31 patients, and BS=30 patients). Baseline characteristics between two groups were not different. The incidence of hyperchlor-emic metabolic acidosis was 17 (54.8%) and 10 (33.3%) in NS and BS groups, respectively (p=0.091). The hospital mortality and prevalence of acute kidney injury were not different between groups.

Conclusion: In pediatric septic shock, the initial fluid resuscitation with balanced salt solution and normal saline was associated with similar clinical outcomes. However, normal saline solution had a trend toward more frequent hyperchloremic metabolic acidosis in children with septic shock when compared to balanced salt solution.

Authors: Nattachai Anantasit, Sriwanna Thasanthiah, Rojjanee Lertbunrian

Predicting the circulation’s response to fluid resuscitation


Fluid resucitation plays a crucial role in pediatric resuscitation. Predicting fluid responsiveness is important as excessive fluid may decrease cardiac efficiency, and even induce overload. Various pathophysiology of shock suggest that fluid only benefit in optimizing preload. Various methods to assess fluid responsiveness includes measurement of static preload indices, dynamic indices to estimate volume status, and the use of protocols such as fluid challenge and passive leg raising technique. This paper highlights the mechanisms behind each measurements and summarized their use as predictor of fluid responsiveness in pediatric patients.

Authors: Antonius Hocky Pudjiadi

Toxic shock syndrome related to the use of a menstrual cup in a pediatric patient


Menstrual cups, made of hypoallergenic rubber or silicone, were first marketed in the 1930’s but have become increasingly popular. Menstrual cups may be less expensive, more environmentally friendly and potentially a safer alternative to tampons and menstrual pads, although the safety of these cups is unknown. We report a case of a 17.5-year-old female who developed probable toxic shock syndrome related to use of The DivaCup®. We suggest that women presenting with signs and symptoms of toxic shock syndrome be asked specifically about their use of a menstrual cup in addition to tampons, because it may be a risk factor and present requires prompt removal for source control.

Authors: Lucy B. Stanke, Elizabeth A. Farrington, Michael Stoiko

Cerebral pontine infarction after postpartum hemorrhagic shock


Cerebral pontine infarction is a rare complication of hemorrhagic shock. We report an unconscious 30-year-old woman that was admitted with severe postpartum hemorrhage (PPH). The patient required two surgery to control the bleeding. Focal neurologic deficit was recognized after extubation. Computed tomography (CT) scan showed findings which were consistent with acute right-side pontine infarction. The patient’s symptoms improved with anti-thrombotic therapy and she was discharged on the thirteenth day of hospitalization. A routine stroke rehabilitation program was planned.

Authors: Faisal Muchtar, Syafri Kamsul Arif, Andi Husni Tanra, Hisbullah Amin, Arif Santoso, Mardiah Tahir

Association of fluid balance during first 48 hours and length of mechanical ventilation in pediatric intensive care unit


Background: Prolonged mechanical ventilation can increase mortality and morbidity rate. Study shows that positive fluid balance associated with prolonged mechanical ventilation, longer hospital length of stay, and higher mortality rate in acute lung injury. We conducted this study to show the association of fluid balance and duration of mechanical ventilation in the pediatric intensive care unit.

Methods: This was an analytic observational study in children one month to 18 years old who admitted to Pediatric Intensive Care Unit (PICU) Haji Adam Malik General Hospital Medan during April-November 2019. Fluid balance was recorded during first 48 hours in PICU. Bivariate analysis was done to analyse association of fluid balance and length of mechanical ventilation with logistic regression analysis for the mortality.

Results: One hundred and seventy-one children were included in this study. Positive fluid balance was found in 102 children (59.6%) with length of mechanical ventilation mostly under seven days (64.3%). Chi-square test showed significant association between fluid balance and duration of mechanical ventilation (p<0.001). Univariate logistic regression analysis showed that fluid balance had no significant association with mortality, but Pediatric Logistic Organ Dysfunction-2 (PELOD-2) and Pediatric Index of Mortality 2 (PIM2) had significant association with OR 2.6 (1.6-4.4) and 1.05 (1.02-1.08), respectively. Multivariate model also indicated that PELOD-2>8.5 and PIM2>30% showed significant association with mortality (OR 2.6 [1.6-4.4] and OR 1.05 [1.02-1.08], respectively).

Conclusion: Fluid balance was associated with length of mechanical ventilation, but no effect on mortality. Multivariate model showed independent association of PELOD-2>8.5 and PIM2>30% with mortality.

Authors: Andriamuri P. Lubis, Aridamuriany D. Lubis

Left ventricular end-diastolic volume index as a predictor of fluid responsiveness in children with shock

Objective: To identify role of left ventricular end-diastolic volume index as predictor of fluid responsiveness in children.
Design: This was a diagnostic study in children with shock in the Emergency Room and Pediatric Intensive Care Unit of Cipto Mangunkusumo Hospital from June to November 2018. The left ventricular end-diastolic volume index measurements were performed using ultrasonic cardiac output monitor and compared to the increase in stroke volume of ≥15% after fluid challenge as fluid responsiveness criteria. Sample categorized into fluid responsive and non-responsive.
Results: Of 40 subjects, 60 fluid challenge samples were obtained. There were 31 and 29 samples in the fluid responsive and non-responsive group, respectively. There was no significant mean difference in left ventricular end-diastolic volume index in the two groups (p=0.161). The area under the receiver operating characteristic (AUROC) of left ventricular end-diastolic volume index was 40.9% with cutoff value of 68.95 ml/m2. The sensitivity and specificity were 45.16% and 44.83%, respectively. At the left ventricular end-diastolic volume index value of 81.10 ml/m2, the specificity was 72.41% with 22.6% sensitivity.
Conclusion: This study cannot prove left ventricular end-diastolic volume index can act as a predictor of fluid responsiveness in children.

Authors: Ahmad Bayu Alfarizi, Antonius Hocky Pudjiadi, Rismala Dewi

On becoming a COVIDologist: An intensivist tale

In late December 2019, I was made aware of a novel coronavirus, which had been identified as the cause of a cluster of pneumonia and acute hypoxemic respiratory failure in Wuhan, China. As we are now aware, this coronavirus disease 2019 (COVID-19) outbreak became a global pandemic. Over the next several months, I read everything I could about this illness, from basic epidemiology to advance diagnostic and therapeutic methods.

By the end of February of 2020, a series of cases were reported in the United States, and large mass gathering events were cancelled. At that time, I knew I was going to be called upon to take care of these patients in a very short period of time.

Authors: Joseph Varon