Age factor and COVID-19: Are there limits to be admitted in the ICU? An ethical issue


Objective: The aim of this article is to clarify different aspects including ethics about the elderly patients during coronavirus disease 2019 (COVID-19) scenario in Spain.

Design: Retrospective, observational.

Methods: Description and comparison of all age groups by confirmed cases and hospitalizations, with special emphasis on those elderly admitted to the intensive care unit (ICU) and mortality. Study of the ethical recommendations of different Spanish scientific societies with treatment proposals for the elderly group. Patients were divided into 6 different age groups. Group I (0-14 years), Group 2 (15-29 years), Group 3 (30-49 years), Group 4 (50-69 years), Group 5 (70-79 years), and Group 6 (>80 years).

Results: The number of confirmed cases during the study was 250,273 and 20,534 deaths. The global mortality was 8.2%. Number of hospitalized patients was 37.1% and 18.25% died. Three point one percent were admitted to the ICU with a mortality of 30.4%. ICU admission ratio: Group 4 51.7%, Group 5 28.4%, and Group 6 4.95%. Average age survivors were 58 (44-76 years), 83 (75-89 years) corresponding to Group 5-6. Non-ICU mortality increased to 14.6% in Group 5, while Group 6 achieved the highest mortality (21.7%).

Conclusion: The number of elderly patients admitted to the ICU was exceptionally low.

Authors: Santiago Herrero

Ultrasound cardiac output monitor inter-rater agreement in Pediatric Intensive Care Unit


Objective: Although Ultrasound Cardiac Output Measurement (USCOM) is relatively simple to operate, its reliability for novice user needs to be assessed. This study aims to determine inter-rater agreement of USCOM between pediatric residents as novices and pediatric intensivist as experienced operator.

Design: An observational study.

Setting: A single-center study in Pediatric Intensive Care Unit.

Patients and participants: Pediatric residents underwent in-house training and 20 practice scans, followed by blinded trans-aortic USCOM cardiac index (CI) measurements made by one of two randomly selected pediatric residents paired with one pediatric intensivist. CI, its categorization and image quality, were noted.

Measurements and results: Paired measurements were performed on 48 subjects. Median of subjects age were 2 years (1 month to less than 18-year-old). Spearman’s rank showed strong positive correlation of CI (rs=0.77; 95% CI=0.62-0.86). Inter-rater agreement by Cohen’s kappa showed substantial agreement on CI (ĸ=0.78).

Conclusion: Following training, pediatric residents were able to measure CI using USCOM with substantial inter-rater agreement.

Authors: Putu Aditya Wiguna, Indah Kartika Murni, Desy Rusmawatiningtyas

Comparison of the resuscitative effects between lactated ringer and lactated ringer/hydroxyethyl starch 6% (200/0.5) combination to serum lactate level in hemorrhagic shock in Lepus nigricollis rabbits


Objective: The ideal resuscitative strategy in hemorrhagic shock remains a matter of debate. The standard resuscitation fluid comprises of crystalloid and colloid, such as lactated Ringer’s (LR) and hydroxyethyl starch (HES), respectively. Whether the administration of LR/HES combination can provide better microcirculatory improvements than LR alone is still unknown.

Design: Experimental analytic study comparing the effect between LR and LR/HES (200/0.5) 2:1 combination to serum lactate level in hemorrhagic shock in rabbit (Lepus nigricollis).

Setting: This study was conducted at Hasanuddin University Medical Research Center (HUMRC), Makassar, Indonesia, from July to October 2019.

Patients and participants: A total of 30 Lepus nigricollis rabbits were included in this study. Fifteen animals were allocated in each group.

Interventions: After the initiation of induced hemorrhagic shock, a hypotension period was maintained for 30 minutes using infusion of LR/HES 6% (200/0.5) 1:2 combination if mean arterial pressure (MAP) decreased more than 30% from baseline, or if there was continuous bleeding if MAP was decreased less than 20% from baseline. The animals in LR group were then resuscitated with LR, while the animals in combination group were resuscitated with LR/HES 6% (200/0.5) 2:1 30 ml/kg/hour, then continued with 3 ml/kg/hour.

Measurements and results: Serum lactate level was measured at baseline, after the initiation of hemorrhagic shock, and after resuscitation. After hemorrhage was initiated, 19 animals had a <20% decrease in MAP and 11 animals had a ≥20% decrease in MAP. There was a significant decrease in serum lactate level in both LR and combination group with <20% decrease in MAP. LR group had a significant difference in serum lactate level from before and after resuscitation, whereas in combination group, only those with <20% decrease in MAP had a significant difference. There were no significant differences in the changes of serum lactate level between both groups.

Conclusions: Resuscitation in both groups may decrease serum lactate level in hemorrhagic shock, and resuscitation with LR/HES 6% (200/0.5) 2:1 combination provided better improvement than LR alone.

Authors: Faisal Muchtar, Syafri Kamsul Arif, Andi Husni Tanra, Arif Santoso, Made Wiryana, Agussalim Bukhari, Nurpudji Astuti Daud, Hisbullah, Warsinggih, Ilhamjaya Patellongi

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

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

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

Lung injury prediction score as a predictor of acute respiratory distress syndrome in intensive care unit


Background: Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by acute hypoxemia and bilateral infiltrates in the lung after a triggered injury. A major obstacle in ARDS prevention is the identification of patients at risk of ARDS. The goal of this study was to assess the validity of lung injury prediction score (LIPS) as a predictor of ARDS in the intensive care unit (ICU).

Patients and methods: This is a retrospective observational study conducted in the ICU of Sanglah General Hospital (Bali, Indonesia) in 2019 with 451 subjects were eligible after a systematic random sampling method. Receiver operating characteristics (ROC) analysis was used to assess the ability of LIPS to predict ARDS and determine the best cutoff point for LIPS in predicting ARDS.

Results: The area under ROC curve (AUC) value was 0.86 (95% CI 0.81-0.91). The best cutoff point was at LIPS ≥5 (sensitivity 85.71%, specificity 80.77%). From a cross tabulation calculation, we obtained a relative risk of 18.6 (95% CI 7.4-46.77). A logistic regression analysis obtained an odds ratio of 1.71 (95% CI 1.45-2.03).

Conclusion: LIPS is valid for predicting the incidence of ARDS in ICU patients. It can be used as a screening tool to identify those with a high risk of developing ARDS.

Authors: Tjokorda Gde Agung Senapathi, Made Wiryana, I Made Gede Widnyana, Christopher Ryalino, Budi Hartono

Can emergency medicine residents diagnose neurogenic stunned myocardium in the emergency department by Focused Assessment Diagnostic Echocardiography?


Purpose: To assess the ability of trained emergency medicine (EM) residents to diagnose neurogenic stunned myocardium (NSM) in patients with acute intracranial events in the emergency department (ED) using the Focused Assessment diagnostic Echocardiography (FADE).

Methods: This prospective cross-sectional study was conducted between February 2018 and January 2019. First, four postgraduate year-3 (PGY-3) EM residents were trained through participation in 10 hours of theoretical FADE education and 20 hands-on FADE on ED patients. Then, adult patients (aged over 18 years old) with acute cerebrovascular accidents (CVAs) were enrolled in the study. Patients with a history of prior cardiac disease, concurrent CVA and ST-elevation myocardial infarction (STEMI), and cardiopulmonary arrest in the ED were excluded. The results of echocardiography by the cardiologists were considered as the gold standard.

Results: Eighty-five cases were enrolled in the final analysis. The mean age of participants was 62.7 years, and 47 (55.3%) were male. There was a good agreement between the EM residents and cardiologists in diagnosing left ventricular (LV) dysfunction (Cohen’s Kappa=0.7, 95%CI=0.65-0.8). Troponin I was positive in 3 (3.5%) patients. Based on the diagnosis of cardiologists, all three patients had heart failure and received a definitive diagnosis of NSM. Whereas, according to the FADE exam by EM residents, 2 out of 3 cases with positive enzyme had heart failure (interrater agreement=66.6%).

Conclusion: Our study showed that trained EM residents could use the FADE exam to diagnose the NSM in CVA patients in the ED.

Authors: Ehsan Karimialavijeh, Aaliyeh Zarrabi, Hamideh Akbari, Mehrad Aghili, Elnaz Vahidi, Fatemeh Rasooli

Vasopressor dependency index: a quick prognostic parameter of septic shock patient in emergency and intensive care unit in remote area


Objective: The aim of the this study was to find out the outcome differences in septic shock patients based on the vasopressor dependency index (VDI) value at Dr. Soetomo General Hospital Surabaya.

Design: This was an analytical observational research.

Setting: Resuscitation Room of Dr. Soetomo General Hospital Surabaya from March to May 2019. This study was approved by the Research Ethics Committee of Dr. Soetomo General Hospital Surabaya.

Patients and participants: The inclusion criteria was septic shock patient who met sepsis-3 criteria. There were 44 samples in the inclusion criteria.

Interventions: Samples were taken by consecutive sampling. VDI was measured starting from 10 minutes, 1 hour, 6 hours, 12 hours, 24 hours, and 48 hours after the treatment of vasopressor drug.

Measurements and results: The most common causes of sepsis was pneumonia (47.7%). Septic shock patients were given norepinephrine (80.0%) as the first line vasopressor drug. There were patient outcome differences within 7 days of treatment based on the VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variable to the patient outcome (p=0.034). The VDI value threshold of the 24th hour was 0.176/mmHg (81.8% sensitivity; 85.2% specificity; 95% CI 0.818-1.000; p=0.000) and of the 48th hour was 0.150/mmHg (88.9% sensitivity; 92.6% specificity; 95% CI 0.859-1.000; p=0.000).

Conclusion: There were significant differences in septic shock patient's outcome in the first 7 days of treatment based on VDI value. The VDI value at the 24th hour and the 48th hour were the most influential variables to the patient outcome (p=0.034). The threshold of VDI at the 24th hour was 0.176/mmHg. The threshold value of VDI at 48th hour was 0.150/mmHg.

Authors: Imamuddin Arif Wicaksono, Arie Utariani, Kuntaman

Venous-arterial CO2 difference to arterial-venous O2 content difference ratio as marker of resuscitation in pediatric septic shock


Objective: Sepsis is still a major cause of mortality in pediatric intensive care units. During initial resuscitation, central venous oxygen saturation (ScvO2) and/or lactate level have become a standard monitoring target nowadays. Carbon dioxide (CO2) partial pressure difference between central vein and artery (Pv-aCO2) has also been recommended as an additional marker to identify persistent global hypoperfusion. Recently, the Pv-aCO2/Ca-vO2 ratio, which represents respiratory quotient, is presumed to be superior in detecting anaerobic metabolism.

Design: Single center observational analytic research with cross-sectional study.

Setting: Resuscitation Room at academic hospital.

Patients and participants: Twenty-four pediatric patients with septic shock, aged 2 months to 12 years old.

Interventions: Patients were resuscitated at the Emergency Department of Dr. Soetomo General Academic Hospital, Surabaya. Initial first hour therapy included oxygenation, antibiotic administration, fluid bolus, and catecholamine titration. Central venous catheter was inserted in all patients through subclavian or jugular veins.

Measurements and results: Lactate was measured in the first and third hour after patient arrival. Arterial and central vein blood gas analysis was performed concurrently at the third hour. Patients were followed up after 48 hours to assess outcome. Pv-aCO2/Ca-vO2 ratio was more effective compared to ScvO2 and lactate clearance in predicting the 48-hour mortality rate (p 0.047). The cutoff value of the Pv-aCO2/Ca-vO2 ratio of 1.54 had the highest sensitivity and specificity to represent global hypoxia in pediatric patients with sepsis.

Conclusion: Pv-aCO2/Ca-vO2 ratio is a useful marker in predicting mortality in pediatric patients with septic shock.

Authors: Yos Kowara, Arie Utariani, Bambang Pujo Semedi, Purwo Sri Rejeki

Prediction of respiratory complications guided by Clara cell protein CC16 in plasma in polytrauma patients


Objective: To evaluate the value of serum levels of Clara cell protein (CC16) as a diagnostic and prognostic utility in patients with polytrauma and relate these levels to respiratory complications compared to plasma levels of healthy control group.

Subjects and methods: A prospective cohort study was carried out on one hundred and fifty patients with polytrauma (blast, blunt, and penetrating) who admitted to Intensive Care Units of Maadi and Kobry El Kobba Hospitals, Cairo, Egypt, from June 2016 and June 2019. Full history taking, clinical examination, radiology investigations, laboratory investigations, CC16 protein and other inflammatory biomarkers were investigated.

Results: There was no statistically significant difference between both groups as regarding age (p=0.09), comorbid conditions (p>0.05), Glasgow coma scale (p=0.09), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p=0.07) and abbreviated injury scale (p=0.08). Along 5 days there was a significantly higher C-reactive protein (CRP) level, neutrophil-lymphocyte ratio in Group I. PO2 level was significantly higher in the first 2 days in Group II than Group I. Chest computed tomography (CT) scan revealed the presence of lung contusion in 30 patients, hemothorax in 20 patients, and pneumothorax in 25 patients, all in Group I. Also, there was a statistically significant difference on day 0 between both groups with much higher serum CC16 in Group I than Group II, while on day 3 the difference was insignificant. Whereas, respiratory complications were significantly higher serum and broncho alveolar lavage (BAL) level of CC16 on day 3, while this difference was insignificant on day 0.

Conclusions: These findings showed that we may benefit from detecting serum CC16 levels in polytrauma victims in prediction of respiratory complications.

Authors: Kamel Abd El Aziz Mohammed Abd Allah, Moataz Mohamed Ibrahim Aly, Ibrahim Mohamed Atia, Samir El Hadedy Tawfik, Khaled Farid Mohamed Hassan