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

Treatment of COVID-19 is critically phase specific

A number of beneficial (corticosteroids and remdesivir), and potentially beneficial therapies, exist for the treatment of COVID-19. What is not widely appreciated is that patients with COVID-19 progress though several distinct phases, with each stage having a different treatment strategy (Figure 1). This fact is of critical importance in achieving the best possible outcomes of this disease. The symptomatic phase is marked by enormous viral replication reaching viral loads in the upper respiratory tract in excess of a billion virions per milliliter, with a very limited host inflammatory response. While patients may remain SARS-CoV-2 PCR positive for weeks (and in...

Authors: Paul E. Marik, Joseph Varon, Pierre Kory

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

Psychological dependence to mechanical ventilation

In the last 50 years, medicine in intensive care units has focused in improving quality and safety processes involved in the attention of critically ill patients, and to reduce co-morbidities associated with these units. This goes beyond offering new treatments or drastic and innovating changes in the intervention of these conditions. (1)
Methods and ways in which these processes are carried out, have become crucial points of the assessment in patient care.
We are referring to psychiatric disorders frequently associated with critically ill patients, out of which delirium is the most studied one. However, depression and anxiety will also often be present, resulting in an extended hospital stay and/or complications.
Mechanical ventilation is an immediate synonym of anxiety, just like it’s also a necessary treatment for patients with respiratory distress, frequently used in intensive care units. When the critically ill patient’s basal condition that led them to need said support, has improved, its withdrawal, also necessary, turns into another problem to take into account, and a number of complications may arise in the process. (2)
One of the aspects, long evaluated, has been ventilator weaning, of which much has been talked about, and different approaches for its achievement have been proposed, as well as the measurement of pulmonary function tests, in order to ensure a successful extubation.
The main determinants of the outcome of weaning include the adequacy of pulmonary gas exchange, respiratory muscle function and psychological problems. (3)

Psychological dependence to mechanical ventilation


From Wallenberg’s to SIRS: A tale of a critically ill physician

Who knows more about a disease than the one who suffers it? That’s the repeated phrase that my anatomy teacher used to say everyday while I was a first-year medical student. At that time, it was just a phrase. It made me think that we only understand but suffering. And recently, that was the case.
From Wallenberg’s to SIRS- A tale of a critically ill physician


Therapeutic hypothermia: Myths and controversies

The use of therapeutic hypothermia (TH) in critical care medicine is no longer a rarity. (1-3) This technique is no longer an urban myth. A variety of robust clinical trials have documented the advantages of using this therapeutic modality in comatose victims of cardiac arrest with successful return of spontaneous circulation (ROSC). (4,5)
TH has many potential applications other than cardiac arrest victims with ROSC and coma. (1,6) Data is available for a variety of critical conditions. Current data clearly indicates that TH protects the cells against the aggressors in hypoxic or anoxic events (not only cardiac-related). (6) TH can protect the microvasculature, reducing the expression of reactive oxygen species; inhibiting adhesion, activation, and accumulation of neutrophils, preserving the adenosine triphosphate storages and maintaining an aerobic metabolism. (1,6)Therapeutic hypothermia: Myths and controversies


The “in extremis” call: When your friend is the one calling!

Years ago, I remember vividly reading an article by the
late Dr. Roger Bone, where he described his emotions and
experience with his illness. I was quite captivated by
such description that I though, eventually I would write a
similar piece. However, to my surprise, over the past weeks
I have encountered an unprecedented feeling towards the
practice of medicine that involved caring for one of my best


The Medical Emergency Team and prevention of sudden cardiac death: where is the data?

Traditionally, cardiopulmonary resuscitation (CPR) has been the main tool for treating victims of cardiac arrest. This therapeutic modality has been known for millennia, and despite its widespread use for the last five decades, it has had only few modifications. The popular belief that CPR is an effective approach for patients with cardiopulmonary arrest has been supported by television medical drama series that always show CPR as a medical icon. (1) However, even when CPR is performed by trained providers, the outcomes remain quite poor, with most patients who require in-hospital CPR dying before hospital discharge, with survival to discharge rates that range from 1 to 20%.


Therapeutic hypothermia in the year 2010: it is about time!

The use of therapeutic hypothermia (TH) in clinical medicine is no longer a rarity. Since the modern inception of this technique by Fay in the 1940s, TH has been used for a variety of clinical scenarios. (1,2) TH has gained significant popularity as a brain-protection strategy in victims of sudden cardiac death in whom return of spontaneous circulation (ROSC) has been obtained with coma. (3) Nonetheless, many trials and case series have shown the advantageous effects of lowering the body’s core temperature in a variety of other clinical conditions including near-drowning, hypoxemic brain injury, traumatic brain injury, traumatic cardiac arrest,


Hypertensive Emergencies: Time for Guidelines

Hypertension remains the “silent killer”. Over 72 million Americans suffer from this condition and it is estimated that as many as 1 billion people worldwide may have it [1]. Critical care clinicians are likely to encounter patients with this malady. Indeed, one percent of patients with essential hypertension (HTN) will develop at some point in their life a hypertensive crisis [2].
What is more concerning, is the fact that the mortality from acute severe HTN remains high. The author participated in a multicenter registry to be published in the next few months. In this registry (studying the treatment of acute hypertension or STAT), an alarming number of patients were readmitted within one month of their initial admission for another hypertensive crisis. Moreover, these patients had an in-hospital mortality that exceeded that of congestive heart failure.
In this issue of Critical Care and Shock, Benson et al, in a large web-based survey, assessed the patterns of drug utilization and management in patients with acute HTN [3]. This original investigation yielded results which are quite interesting and distressing. As the authors indicate, no national practice guidelines exist in the United States for the treatment of patients with acute severe HTN. The authors characterized the utilization patterns of intravenous antihypertensive agents among physicians and clinical pharmacists members of the Society of Critical Care Medicine (SCCM) and the American College of Clinical Pharmacy (ACCP).
Looking at the patterns of utilization we can infer that despite advances in the understanding and management of this illness, many clinicians continue to utilize agents with poor safety profi les. A remarkably high number of them use sodium nitroprusside in this setting. This is disconcerting as 44 percent of the fractional weight of this agent is cyanide and the therapeutic spectrum is very narrow [4]. Moreover, 36% of respondents had seen patients with cyanide or thiocyanate-induced toxicity [3]. So, why do we still use agents that are potentially lethal?
In many instances, and in many countries, the lack of other intravenous antihypertensive agents is the primary concern. However, in Western countries, where other agents are available (i.e., nicardipine, clevidipine, labetalol) misinformation and lack of knowledge are the primary reasons for clinicians to utilize these dangerous agents. In the author’s personal experience there are many options for clinicians to utilize in cases of acute severe HTN in a variety of settings [5].
The article by Benson and coworkers reminds us for the need of national practice guidelines in the fi eld of acute HTN. This illness is likely to remain a common cause of long-term disability and still an exceedingly high mortality in acute care medicine.


Information Exchange in Critical Care for a Better Future

In the year 2008, knowledge and technology develop continually in every field of our lives, and, with no exception, in critical care medicine as well. This continuous growth is implicit in our daily activities. We could not imagine our lives today without it. Nowadays, as health care professionals, we surely do not want a fever to last for one week before we can make a diagnosis of typhoid fever for our patients. We can use some simple tests instead and institute prompt therapy.
We believe that these rapid developments in the acute care medicine fi elds motivated Dr. Iqbal Mustafa 11 years ago to found this Critical Care and Shock Journal; a Journal that despite many other similar journals has persisted and evolved. It was Dr. Mustafa who realized that the development of international communications would only give benefit to mankind if it could be spread out, especially within the scientific community. Dr. Mustafa’s knowledge and ability in critical care medicine as well as his willingness to promote Indonesia and other Asia Pacific countries in that field, and good relationship with his colleagues worldwide have made this Journal publication easier.
Against this backdrop many foremost authorities in critical care medicine submitted their articles to be published in Critical Care and Shock. A few years later this Journal was adopted as one of the official journals of the Asia Pacific Association of Critical
Care Medicine (formerly known as the Western Pacific Association of Critical Care Medicine). Uniquely, as we previously wrote in Critical Care and Shock Vol. 7 No. 3, the authors from many countries were brought together in a yearly medical conference in Bali, which we all know as the International Symposium on Critical
Care and Emergency Medicine.
The year 2008 marks the fifteenth anniversary of this conference; we still wish that our goal to academic and clinical progress will be achieved through the exchange of information in this international, multidisciplinary conference. We would like to take this opportunity to thank all the speakers and participants who are
willing to contribute their invaluable knowledge and time in this prestigious event. Congratulations to the Organizing and Scientific Committees on their tireless efforts to organize this meeting yearly.