Vitamin D deficiency and outcome of patients with sepsis in pediatric intensive care unit: a prospective observational study


Background: Vitamin D is important in immunomodulation, regulation of inflammation and cytokines, cell proliferation, cell differentiation, apoptosis, angiogenesis, muscle strength, and muscle contraction. Patients with sepsis have high mortality rate and high deficiency in vitamin D. (1) Vitamin D is increasingly recognized as an important mediator of immune function and may have a preventive role in the pathogenesis of sepsis. (2) Vitamin D also influence cardiovascular function. (3) We aimed to find the correlation of vitamin D level with severity of sepsis in patients admitted to pediatric intensive care unit (PICU).

Setting: Participants and laboratory were collected from patients with sepsis who admitted to the PICU at Dr. Sardjito General Hospital, Yogyakarta.

Patients and Participants: Participants pediatric sepsis patients admitted to the PICU from September 2015 to April 2016. Blood samples for 25-hydroxyvitamin D [25(OH)D] concentration were collected at the first 24 hours admission in PICU using ELISA method. Other data recorded include pediatric logistic organ dysfunction (PELOD) score at admission, PICU length of stay and mortality.

Measurement and results: A total of 297 patients were admitted to the PICU during the 8-month study period. Fourty-two patients had diagnosis of sepsis, severe sepsis or septic shock on PICU admission. Of all these studied patients, 25(OH)D deficiency was identified in 23 (54.8%) patients, insufficiency in 9 (21.4%) patients, and normal levels in 10 (23.8%) patients. PICU mortality was higher in patients with 25(OH)D deficiency, ie 7 (30.44%) patients, but it did not show any statistical significance compared to the group of patients with 25(OH)D insufficiency or normal level of 25(OH)D group of patients (p=0.78). The group with normal level of 25(OH)D had the highest PELOD score but on the other hand they have the lowest mortality rate.

Conclusions: There is a high prevalence of vitamin D deficiency in pediatric sepsis patients admitted to PICU, but not correlated with PELOD score on admission. PICU lenght of stay also not associated with mortality in PICU.


Electrocardiography Holter monitoring abnormalities in acute intracerebral hemorrhages


Objective: To avoid the misinterpretation of electrocardiogram (ECG) abnormalities in acute intracerebral hemorrhage (ICH), it is important to recognize ECG abnormalities in such patients. Previous studies have reported ECG disorders in ICH patients based on a single ECG tracing. In this study, we used ECG Holter monitoring to determine ECG abnormalities in acute ICH patients.

Methods: This was a prospective analysis of acute (up to 24 hours following admission) non-traumatic ICH patients who were admitted to our hospital between January 2014 and April 2015. Initially, an ECG and cerebral computed tomography (CT) scan were obtained within the first day of admission. The patients then underwent ECG Holter monitoring for 24 hours. Finally, the ECG abnormalities and their association with the CT scan findings were analyzed.

Results: This study included 108 patients with acute non-traumatic ICH. The most frequent ECG abnormalities shown by Holter monitoring were ectopic beats (85.2%), followed by sinus tachycardia (63.2%). Only the presence of midline shift on the CT scan had a significant correlation with ectopic beats (OR: 1.3, CI: 1.05-1.7).

Conclusion: ECG Holter monitoring in 108 acute ICH patients demonstrated a correlation between the presence of midline shift on the cranial CT scan and ectopic beats in the ECG Holter monitoring.

Authors: Marjan Asadollahi, Mahtab Ramezani, Fatemeh Sharif, Ehsan Karimialavijeh

Initial caloric administration as a risk factor for mortality in critically ill children


Background: The mortality rate of critically ill children with multiple organ dysfunction syndrome (MODS) in Indonesia is approximately 51.85%. Various studies suggested malnutrition as a risk factor for mortality; therefore, nutrition therapy in the form of initial caloric administration became imperative.

Objective: To determine the relationship between initial caloric administration (initial route, initial time and the fulfilment of caloric requirement) and mortality of critically ill children.

Design: Case-control study.

Setting: The Pediatric Intensive Care Unit (PICU) of Dr. Sardjito General Hospital Yogyakarta in 2015.

Patients and participants: Children aged 1 month to 18 years old hospitalized in the PICU for at least 4 days in 2015. Subjects were divided into case group (non-surviving patients) and control group (surviving patients).

Measurements and results: We used McNemar test and stepwise conditional logistic regression for data analysis. From 102 subjects (51 in each group), the proportion of malnourished children in the case group was higher than in the control group (58.8% and 29.4%, respectively). Parenteral route and lack of caloric achievement within the 3rd to 6th day of hospitalization significantly increased the risk of mortality (p<0.05) with ORs of 13 (95%CI 1.95 to 552.47), 3.8 (95%CI 1.37 to 13.02), 4.25 (95%CI 1.39 to 17.26), 4.00 (95%CI 1.08 to 22.09), and 10.0 (95%CI 1.42 to 433.98), respectively. Caloric initiation after the first 48 hours of hospitalization did not significantly affect the mortality rate (p>0.05). Confounding variables that affected mortality include the severity of disease, use of ventilator, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and malnutrition (p<0.05). Multivariate analysis revealed that parenteral route and malnutrition significantly influenced mortality with ORs of 36.05 (95%CI 3.22 to 404.13) and 9.04 (95%CI 2.09 to 39.19), respectively.

Conclusion: There is a relationship between route of initial caloric administration and mortality of critically ill children, where parenteral nutrition significantly influenced mortality in critically ill children.

Authors: Melia Yunita, Titis Widowati, Nurnaningsih, Desy Rusmawatiningtyas

The case of the malpositioned feeding tube… while in plain sight

Patient WS is a 63-year-old male who presented to the Emergency Department (ED) with a chief complaint of progressive shortness of breath (SOB) over the past two weeks. Associated symptoms at time of presentation included acute bilateral lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. His past medical history was significant for diabetes mellitus type II, hypertension, hypothyroidism, paroxysmal atrial fibrillation, paroxysmal ventricular fibrillation, non-ischemic cardiomyopathy (ejection fraction of 25%), severe mitral valve regurgitation, and newly diagnosed adenocarcinoma of the colon. The patient’s surgical history was significant for bi-ventricular ICD placement and gastric sleeve surgery.

Authors: Thomas Lynch V, Brian T. Wessman

Three years after the REDOXS study: What we have learned in the use of glutamine in ICU patients?


Critical illness has been associated with glutamine (Gln) plasma levels depletion and its supplementation is related with better outcomes. In 2013 the Reducing Deaths due to Oxidative Stress (REDOXS) study, showed that the supplementation of Gln to total parenteral nutrition was associated with higher mortality without conferring beneficial effects. These conclusions had a high impact in the clinical field: two of the main guidelines downgraded its recommendation. However, recent studies are answering questions regarding the safety use of this amino acid use and even suggesting new potential beneficial effects.

It is important to understand the main lessons learned of the REDOXS study related to the correct use of Gln intra venous and do not rule out its use for the intensive care unit patients. The scientific community is actively working in the field and we expect to have more evidence to guide the correct of this amino acid in parenteral nutrition.


Ureteral stents, sepsis and acute kidney injury: Iatrogenic imperfecta!

Case presentation

A 62-year-old woman with a past history of placement of bilateral ureteral “JJ” stents, presented to the hospital complaining of fever, chills, abdominal pain, oliguria and was found to be hypotensive. She was admitted to the intensive care unit (ICU), with the diagnosis of sepsis secondary to a urinary source. Her white blood cell count (WBC) was 21,200/mm3, blood urea nitrogen (BUN) 40 mg/dL, and serum creatinine 2.1 mg/dL. Her systolic blood pressure was 75 mmHg after administration of bolus of intravenous fluid (30 ml/Kg). She was then started on norepinephrine with improvement in her mean arterial blood pressure.


Mediastinal lipoma with vascular compression

Case description

A 56-year-old gentleman presented to the emergency department with shortness of breath and neck swelling of a couple of weeks duration. After a comprehensive physical examination and chest radiograph revealing an upper mediastinal abnormality, a computed tomography (CT) scan of the chest (Figures 1A and 1B) depicted a 8x7x5.7 cm mass with homogenous fat density and smooth margin, that was causing compression and anterior displacement of the superior vena cava and the left brachiocephalic vein. The patient underwent urgent surgery with removal of the tumor and postoperatively his symptoms had subsided.


Characteristics of the obstetric patients admitted to the Intensive Care Unit of Sanglah General Hospital in 2013-2016


Background: High risk pregnancy and complication during pregnancy or labor may need multidisciplinary management in the Intensive Care Unit (ICU). This study shows the characteristics of obstetric patients who were admitted to the ICU of Sanglah General Hospital Denpasar, Bali, Indonesia in 2013 to 2016.

Objective: Our study was performed to provide database in Sanglah General Hospital regarding to the intensive care management of obstetric patients in the ICU of Sanglah General Hospital. This data may be beneficial to provide better management in the ICU, and also to reduce maternal mortality and morbidity.

Design: This was a descriptive study using the secondary data from the medical records of obstetric patients who were admitted to the ICU of Sanglah General Hospital in 2013 to 2016.

Setting: This study was performed in the ICU of Sanglah General Hospital, Denpasar, Bali, Indonesia.

Patients and participants: All obstetric patients who were admitted or transferred to ICU of Sanglah General Hospital in August 1, 2013 to August 31, 2016. There were 245 obstetric patients transferred to ICU of Sanglah General Hospital.

Result: Over the 3 years study period, there were 245 obstetric patients who were admitted to the ICU out of the total of 3089 deliveries during that period. Based on the gestational age during admission, there were 7.7% cases below 28 weeks (n=19), 36.3% were between 28-36 weeks gestational age (n=89), and 55.9% cases were 37 weeks and above (n=137). The indication of the admission can be categorized into the obstetrics indication, which were 75.1% out of 245 cases (n=184) and the non-obstetric indication such as the medical problem underlying during the pregnancy, which were about 24.9% out of 245 cases (n=61). The major indication of obstetric problem was the hypertensive disease in pregnancy, while the major indication of nonobstetric reason was the heart disease. The maternal mortality rate in the ICU during this study was 10.2% out of the 245 cases who were admitted to the ICU.

Conclusion: As the major tertiary referral hospital in Bali, Sanglah General Hospital were having high number of complicated pregnancy cases. The characteristics of the obstetric patients who were admitted to the ICU can be used to plan better management and appropriate care, especially in the ICU, in order to reduce the maternal mortality rate.


Prevalence and association of cost and hospital malnutrition in Pediatric Intensive Care Unit Sanglah Hospital during 2015


Background: Early nutritional screening and adequate enteral nutrition for critically ill patients, started 24 hours after admission in pediatric intensive care unit (PICU) are accepted to improve health outcomes. Malnutrition prior to admission worsens the prognosis of severely ill children and it will lead to a higher mortality, a longer length of stay, and a higher health cost.

Objective: The main outcome was to investigate the prevalence of hospital malnutrition on admission, discharge, and in-hospital in PICU Sanglah Hospital, Bali during 2015. The secondary outcome was to investigate the association of cost and hospital malnutrition.

Methods: A retrospective study was conducted in PICU Sanglah Hospital, Bali, from January to December 2015.

Patients and participants: Children aged 1 month to 12 years with complete medical records. We assessed the prevalence of hospital malnutrition using WHO Anthro software or WHO AnthroPlus software.

Results: From January to December 2015, there were 477 patients admitted to the PICU and 456 were enrolled in this study. Malnutrition was observed in 72 patients (15.8%) during PICU admission, 56 (17.2%) during discharged, and only 13 (2.9%) suffered from malnutrition during hospitalization. Multivariate analysis showed that malignancy was the only factor associated with in-hospital malnutrition. Malnutrition during admission and discharge were not associated with an increase in the length of hospital stay. But, in-hospital malnutrition was associated with longer length of stay (3.2 vs 14.0 days, p<0.001), and was associated with additional cost of Rp 5,500,000.

Conclusion: Malnutrition was observed in 72 patients during PICU admission, 56 during discharged and only 13 during hospitalization. Hospital malnutrition was associated with additional cost of Rp 5,500,000.


“Complete” loss of brain stem reflexes - not always brain death! Beware of amitriptyline overdose


We present a case of “complete” loss of brain stem reflexes following amitriptyline overdose, which mimicked brain death. This case highlights the complexities associated with clinical brain death determination and calls for close attention to details.

Based on previously published case reports, we analyse the relationship with the amitriptyline dose, blood level and timing of neurological recovery. Ours is the fourth case report in literature demonstrating “complete” loss of brain stem reflexes following amitriptyline overdose.

The amount of amitriptyline ingested in these cases (including our case report) ranged from 500 mg to 9 g; the blood concentrations ranged from 1.35 microgram/ml to 3.43 microgram/ml. The neurological recovery seems to start by day two to four with complete neurological recovery by day five to seven.