High capillary leak index is associated with increased risk of ICU-related mortality after major abdominal surgery


Objective: Major surgery may induce an inflammatory response, which results in an increased level of C-reactive protein (CRP) and represented in albumin loss to extravascular area due to increased capillary permeability. Our study was to evaluate the association between capillary leak index (CLI) and intensive care unit (ICU)-related mortality in patients underwent major abdominal surgery.

Design: This was a prospective study with cohort analytic design.

Patients and participants: We included adult patients aged 18 and older who were treated in ICU after underwent major abdominal surgery. Patients who were pregnant, having menstruation, relaparotomy, diabetes mellitus, and idiopathic systemic capillary leak syndrome were excluded from this study. Blood was collected before surgery and at 48 and 72 hours after surgery. Patients were observed for mortality incidence during treatment in the unit. The CRP level was measured using ABX Pentra 400 (HORIBA, Germany), whereas the albumin level was measured using HumaStar 80 (HUMAN, Germany). CLI was measured by dividing CRP level by albumin level. Data were analyzed using SPSS Statistics version 21.0 (IBM, New York, U.S.).

Results: CLI at hour 72 was associated with increased risk of ICU-related mortality (RR 21.667; 95% CI 2.938-159.763; p<0.001).

Discussion: Acute inflammation normally resolved within three days. Systematic response to tissue injury, including major surgery, is marked by increased proinflammatory cytokines, which promotes CRP production and capillary leakage. CRP production will increase to its peak level 36-50 hours after inflammation. However, if the injury still exists, inflammatory process will continue.

Conclusions: High CLI at hour 72 can be considered as the risk factor to ICU-related mortality.

Authors: Ade Susanti, Mayang Indah Lestari, Sedono R, Liberty IA

Thromboelastography (TEG) and hemostatic parameters as the diagnostic parameter of septic mortality in the intensive care unit


Objective: This study aimed to determine the relationship between thromboelastography (TEG) and hemostatic parameters and the Sequential Organ Failure Assessment (SOFA) score and mortality of septic patients, and found the potential of those parameters to be the mortality diagnostic parameters.

Design: This was a prospective cohort study.

Setting: This study was conducted in the Intensive Care Unit of Dr. Saiful Anwar General Hospital.

Patients and participant: This study was conducted on thirty septic patients at the Intensive Care Unit.

Measurement and result: Hemostatic parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT], and international normalized ratio [INR]) and thromboelastography parameters (R time, K time, α angle, maximum amplitude [MA], G value, coagulation index [CI], and LY30) were analyzed using the normality test, homogeneity test, t-test, correlation test, and receiver operating characteristic (ROC) curve test in SPSS version 17.0. SOFA scores 8-11 and 12-20 had the highest mortality (100%). R time, K time, CI, α angle, MA, and G value, and all hemostatic parameters significantly correlated with SOFA score (p<0.05). R time, K time, α angle, CI, PT, aPTT, and INR of living patients significantly differed from death patients (p<0.001). K time, α angle, MA, CI, and all hemostatic parameters had an area under the curve (AUC) close to 1 (p<0.05). K time (69.2%) and aPTT (100%) had the highest sensitivity. The positive predictive value (PPV) of all TEG parameters was 100%. aPTT (100%) was the highest in the hemostatic parameters. The hemostatic parameters had a higher sensitivity than its specificity, while the TEG had higher specificity than its sensitivity.

Conclusion: Most thromboelastography parameters and all hemostatic parameters significantly correlated with the SOFA score. K time had the highest sensitivity and specificity as the diagnostic parameter of septic mortality compared to the other thromboelastography parameters, while aPTT was the most sensitive diagnostic parameter of septic mortality compared to other hemostatic parameters.

Authors: Isngadi, Aswoco Andyk Asmoro, Harjuna Atma Wiraharjanegara, Arie Zainul Fatoni

Positive cumulative fluid balance is a risk factor of mortality in critically septic patients


Objective: Excessive fluid administration may increase septic patient mortality. Cumulative fluid balance is an easy, cheap, and non-invasive method of monitoring fluid therapy. Our study aimed to analyze the association between cumulative fluid balance and mortality in critically septic patient.

Design: This was an observational analytic study with a retrospective cohort design.

Setting: This study was conducted in intensive care unit of Mohammad Hoesin Hospital in 2017.

Patients and participants: All adult septic patients from January to December 2017 were included. All patients who did not have completed medical record data were excluded.

Interventions: Data on the mortality and cumulative fluid balance of septic patients were obtained through secondary medical record data and were analyzed using SPSS Statistics version 22.0 (IBM, New York, US).

Measurement and results: Positive cumulative fluid has a very significant association with mortality (relative risk [RR] 3.41; 95% confidence interval [CI] 1.98-5.87; p<0.001). Mean cumulative fluid balance (ml) were greater in non-survivor than survivor group (1937.5±1692.6 vs 877.2±1228). The probability of survival in 28 days was affected by cumulative fluid balance (p=0.001) after being tested with Mantel Haenszel log-rank test. This cumulative fluid balance had a sensitivity of 81.8% and specificity of 89.2% as a predictor of mortality in septic patients.

Conclusions: Positive cumulative fluid balance can be considered as the risk factor to septic patient mortality.

Authors: V. Linardi, SE Handrawan, P. Liana, Mayang Indah Lestari

Comparing asynchrony in two noninvasive ventilators


Objectives: Noninvasive ventilation (NIV) is commonly used in respiratory failure as an alternative to more invasive tracheal intubation. A major challenge of NIV is synchronization between the patient’s spontaneous breathing efforts and the support of the ventilator.

Design: We compared simulator-ventilator synchrony characteristics of two ventilators during noninvasive ventilation, using an adult lung simulator under three leak configurations.

Setting: Bench test with lung simulator.

Patients and participants: Active Servo Lung with the bellavista 1000 NIV (bellavista NIV) and Respironics V60 (V60).

Interventions: Three configurations simulating different levels of unintended leak were tested for each ventilator: No Leak, Continuous Leak, and Inspiratory Leak. The recorded pressure and volume waveforms were analyzed to quantify trigger delay, triggering pressure-time product (PTPtrig), pressure-time product at 300 ms (PTP300), insufflation time excess (TI,excess), and time required to reach 63.2% (Texp,63) and 95.0% (Texp,95)of expired tidal volume (VTexp) for each ventilator in all three leak scenarios.

Measurements and results: Trigger delays for the bellavista NIV were significantly lower for all three leak conditions (p<0.0001) and it responded faster to simulated muscle activity compared to the V60. Both the bellavista NIV and V60 experienced no auto-trigger or missed trigger events. The bellavista NIV reached target pressure values more quickly as indicated by significantly higher PTP300 for all three leak conditions (p<0.0001) and had significantly shorter TI,excess (p<0.0001). The bellavista NIV experienced no delayed cycling breaths while more than 25% of V60 breaths showed delayed cycling during inspiratory leak tests.

Conclusions: The bellavista NIV showed significantly lower trigger delays for all three leak conditions, reached target pressure values more quickly (i.e., higher PTP300), and showed superior cycling performance (i.e., lower trigger delay) compared to the V60, which may improve patient-ventilator synchrony and patient comfort.

Authors: Ross C. Freebairn, Andreas D. Waldmann, Christian Remus, Michael J. Pedro

Early administration of norepinephrine prevents the occurrence of fluid overload in the resuscitation of septic shock patients


Background: Critically ill patients with sepsis usually receive a very large volume of fluids causing a very significant positive fluid balance in an effort to meet the needs of cardiac output, systemic blood pressure, and perfusion to the kidneys. This condition also tends to be associated with poor survival rates. The aim of this study was to determine whether early maintenance of norepinephrine can reduce fluid administration and prevent overload in the resuscitation of patients with septic shock.

Methods: This study was a randomized, non-blind clinical trial, of which the subjects were adult patients with septic shock admitted to the intensive and emergency care unit from January to November 2020. There were two treatment groups of this study, the early norepinephrine group (NEP group) and the 30 ml/kgBW fluid resuscitation one (Fluid group). The test was conducted on the urinary albumin-to-creatinine ratio, increase of serum creatinine value, ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio), and intra-abdominal pressure at the time of septic shock diagnosis was established, 3 hours, and 24 hours after the treatment was given. The data was processed using the SPSS device.

Results: Based on the analysis, it was found that there were significant differences in all study variables of the Fluid group compared to the NEP group. The amount of fluid administration in the NEP group averaged 2198.63 ml, less than that in the Fluid group with an average of 3999.30 ml (chi square test p=0.000). By comparing the measurement results to the initial measurement values in the two groups, the fluid overload was high-risk in the Fluid group. There was a significant relationship between the urinary albumin-to-creatinine ratio (OR=48.273; 95% CI=16.708-139.472), the increase in serum creatinine value (OR=73.381; 95% CI=19.955-269.849), the low PaO2/FiO2 ratio (OR=12.225; 95% CI=5.290-28.252), and the increase in intra-abdominal pressure (OR=32.667; 95% CI=10.490-101.724) with the provision of 30 ml/kgBW fluid resuscitation, which indicated the risk of fluid overload.

Conclusion: Early norepinephrine administration can reduce fluid administration and prevent overload in the resuscitation of patients with septic shock.

Authors: Romi Akbar, Yohanes George, Amir S. Madjid, Rudyanto Sedono, Aida Tantri

Inferior vena cava collapsibility index pre-induction is superior to caval aortic index pre-induction in predicting hypotension after induction of general anaesthesia


Objective: The study aims to compare the pre-induction inferior vena cava collapsibility index (IVC-CI) and caval aortic index (CAo-I) as hypotension after induction of general anaesthesia (GAIH) predictors.

Design: This is an analytic observational study.

Setting: This study was conducted in Dr. Saiful Anwar General Hospital.

Patients and participant: This study was conducted on thirty-six patients undergoing general anaesthesia.

Intervention: IVC-CI and CAo-I were measured before induction using ultrasound guide. Baseline blood pressure, mean arterial pressure (MAP), heart rate, maximum IVC diameter (dIVCmax), aortic diameter (dAo) were recorded before induction, then were repeated five minutes after induction. Patients received general anaesthesia induction using propofol 2 mg/kg. Analgesic using fentanyl 2 µg/kg and muscle relaxant using atracurium 0.5 mg/kg. Patients received preoxygenation of 100% oxygen for 3-5 minutes.

Result: MAP, heart rate, dIVCmax, dAo before and after induction were significantly different (p=0.000). Thirty patients (36.1%) experienced GAIH. There was no significant difference in age, gender, body mass index, physical status, and MAP pre-induction (p>0.05) between the hypotension and no-hypotension group, except for MAP induction (p=0.001). Pre-induction IVC-CI significantly correlated with hypotension (p=0.024; r=0.375), but not in CAo-I (p>0.05; r=-0.100). The receiver operating characteristic test showed that IVC-CI had higher sensitivity (69.57%), specificity (69.23%), and accuracy (69.44%) than CAo-I, with cut-off value greater than 62.70% (confident interval 95%).

Conclusion: Pre-induction IVC-CI is superior to CAo-I in predict hypotension after induction of general anaesthesia.

Authors: Wiwi Jaya, Ristiawan Muji Laksono, Alfons Octavian Sabandar, Arie Zainul Fatoni

Demographic diversity of COVID-19 patients treated at ICU Special Hospital for Infections Surabaya


Background: The diversity demography of coronavirus disease 2019 (COVID-19) has prompted us to collect data in our workplace. These data are essential because they can serve as a data bank of demographics in one big hospital in East Java. We analyzed patients' characteristics with COVID-19 admitted to the Intensive Care Unit (ICU) Special Hospital for Infections, Airlangga University, Surabaya.

Methods: Retrospective study from medical record of 180 patients with confirmed COVID-19 admitted to the ICU Special Hospital for Infections, Airlangga University of Surabaya between April - September 2020.

Results: Most of the patients were male (67.2%), with median age was 55 (22-83) years. The body mass index (BMI) data consisted of normal (48.9%), overweight (39.4%), obesity class I 7.8%, obesity class II 1.1%, obesity class III 0.6%, and underweight 2.2%. We found severe acute respiratory distress syndrome (ARDS) in 63.9%. The use of invasive mechanical ventilation was 74% of the total patients. Most of the patients (85%) had comorbidity: hypertension, diabetes mellitus, and geriatrics. The average length of stay in the ICU was 8.5 days. We transferred 29% of patients to a low-care ward, and 66.7% died. We identified gastrointestinal symptoms on admission to the ICU were 43.3%, predominantly by nausea and vomiting. Forty-six point seven percent of patients with gastrointestinal symptoms during hospitalization consisted of gastric retention and diarrhea, some with hematin.

Conclusion: The demographic data we present above are limited in our area. The demographic data of COVID-19 patients in other places may be different from the information we obtained. However, data like this may represent the patient's condition in areas similar to ours. Besides, this data can warn that the patient's condition, as in our data, requires special attention. It is necessary to add data from all corners of Indonesia to represent the demographic data of COVID-19 patients in Indonesia.

Authors: Diah Wahyuningsih, Anna Surgean Veterini, Hamzah Hamzah, Lucky Andriyanto

Estimates of fluid balance and insensible loss in the critically ill: A cohort study in a non-metropolitan intensive care unit


Assessment of fluid balance has an integral role in management of critically ill patients. Fluid status measurement is multifactorial, comprising of clinical examination, biochemical investigation, and fluid balance records. Error in fluid balance record is well published, as are the adverse outcomes that result from poor fluid control. The current audit was organised to assess the degree of arithmetic error in fluid balance records in Hawke’s Bay Intensive Care Unit (ICU); secondary aims included use and effect of certain diuretic/antidiuretic agents, change in patient fluid status, and change in weight during admission. Twenty ventilated patients admitted to Hawke’s Bay ICU over 14 days (between 1st January 2020 and 24th December 2020) were randomly selected for audit. Twenty-four-hour fluid balance charts were checked, and data regarding secondary outcomes was collected. Seventy point one percent of audited charts were correct, within 0-10 ml from the true fluid balance. Incongruence between change in weight and cumulative fluid balance for 14-day of admission described a 1300 g fluid weight discrepancy, explained by insensible fluid loss.

Authors: Felix Bird, Taylor Campbell, Ross Freebairn

Clinical profile and outcomes in adults with status epilepticus - A prospective observational study


Objectives: Status epilepticus (SE) is a common life-threatening medical emergency, and its neurological outcome requires prompt recognition and management. The present study aimed to determine the clinical profile and outcome of patients with status epilepticus.

Design: Prospective observational study.

Setting: The study was conducted in intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre from March 2018 to September 2019.

Patients and participants: Forty-six status epilepticus patients attending intensive care units under Emergency Medicine, General Medicine, Neuro Medicine, and Neurosurgery Departments of a tertiary care centre were included and followed for 45 days.

Measurements and results: Baseline data on demographics, comorbidities, duration of each episode, number of episodes, treatment, brain imaging findings (computed tomography [CT] and magnetic resonance imaging [MRI]) and other comorbidities. The collected data was analyzed by analysis of variance (Anova) and independent t-test. P-value <0.05 was considered statistically significant. Out of 45 subjects included in the final analysis, 34 (75.6%) survived, and 11 (24.4%) had died during hospitalization. Mean±standard deviation of age was 43.1±1.02. Thirteen (71.1%) had diabetes mellitus as comorbidity. Twenty-four (53.3%) of them had >15 mins of seizure, 22 (48.9%) were in between 5 to 12 of Glasgow coma scale score. Among the study population, the probable etiology was head trauma 5 patients (11%), viral meningoencephalitis 7 patients (15.6%), acute cardiovascular system 9 patients (24.4%), and alcohol withdraw 14 patients (8.9%). Majority of them (18 patients [40%]) required third-line treatment, 33 patients (73.3%) required in hospital ventilator assistance, and 19 patients (42.2%) developed refractory status epilepticus (RSE). The duration of hospital stay was found to be significant for third-line treatment (21.9 days), mechanical ventilation (21.30 days), and RSE (23.8 days) with a p-value of 0.001.

Conclusion: The duration of hospital stay was significantly associated with the findings on brain MRI, the requirement of in-hospital ventilatory support, the treatment given, and the presence of RSE.

Authors: Aiswarya M. Nair, Priyadarshini Varadaraj, Sivaprakash Varadan, Vaasanthi Rajendran, Viswanathan Pandurangan, K. Madhavan, Anurag P.

Receptor-interacting protein kinase 3 has a good accuracy in predicting mortality of critically septic patients


Objective: Sepsis-related uncontrolled systemic inflammation may trigger necroptosis, which is correlated with receptor-interacting protein kinase 3 (RIPK3) level. A high level of RIPK3 is associated with organ dysfunction and thus, mortality. This study aimed to analyze the ability of RIPK3 level to predict mortality in septic patients.

Design: This was a prospective cohort study.

Setting: This study was conducted in intensive care unit from February until August 2019.

Patients and participants: This study included patients aged 18 years or more who met the Sepsis-3 definition. Baseline demographic data were measured.

Interventions: Blood was collected to measure RIPK3 at sepsis recognition. RIPK3 level was measured using enzyme-linked immunosorbent assay using Bio-Rad (Bio-Rad Laboratories, California, US). Hour-1 bundle resuscitation was performed on all participants. Participants were observed for 28 days for mortality. Data were analyzed using STATA program software.

Measurement and results: A total of 59 subjects were analyzed. The cutoff point of RIPK3 level was 0.51 ng/ml with 92.5% sensitivity and 89.5% specificity in predicting mortality. RIPK3 level has an excellent performance with area under the receiver operating characteristic (ROC) curve (AUC) value of 0.925.

Conclusions: RIPK3 level can be considered a useful tool to recognize high risk mortality among critically septic patients.

Authors: Mayang Indah Lestari, R. Sedono, Zulkifli, IA Liberty

Comparison of serum tumor necrosis factor, superoxide dismutase, and heat shock protein-70 levels during cardiopulmonary bypass and ischemia reperfusion injury after cardiopulmonary bypass in cardiac surgery


Objective: This study aims to determine the comparison between tumor necrosis factor (TNF)-a, superoxide dismutase (SOD), and heat shock protein (HSP)-70 levels during cardiopulmonary bypass (CPB) and ischemia reperfusion injury after cardiopulmonary bypass.

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

Setting: This study was conducted at Dr. Soetomo General Hospital Surabaya. The period of study was from April 2020 to September 2020.

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

Measurement and results: All interval data with normal distribution were analyzed using T-pair test. Statistical test using the Wilcoxon signed-ranks test (two-tailed) was performed to determine comparison of TNF-a, SOD, and HSP-70 levels during CPB and after CPB. There were 30 subjects who underwent adult cardiac surgeries including coronary artery bypass graft (CABG), valve, and double procedures. According to statistical test, there was a significant increase of TNF-a, SOD, and HSP-70 levels during cardiopulmonary bypass compared to after cardiopulmonary bypass with p-value <0.05. Pearson correlation test was performed to determine the correlation between elevated levels of TNF-a, SOD, HSP-70 during CPB impact. There was significant correlation between TNF-a and SOD (p<0.05), and also between SOD and HSP-70 (p<0.05).

Conclusion: Our study showed that CPB impact significantly contributes to the increase of TNF-a, SOD, and HSP-70 levels compared to after CPB in patient undergoing on pump cardiac surgeries.

Authors: Teuku Aswin Husain, Setiawan P, Yan Efrata Sembiring, Budiono

Invasive mechanical ventilation during the first wave of COVID-19: Management and outcomes


Objective: To describe demographics, clinical, and respiratory mechanics (including ventilatory management details) of patients admitted to the Intensive Care Unit (ICU) with severe COVID-19 and to evaluate the effectiveness of gas exchange variables, ventilatory parameters, and ICU illness severity scores in predicting 28-day mortality.

Design: Single-center retrospective cohort study.

Setting: Portuguese medical-surgical ICU.

Patients: Adults sequentially admitted to the ICU, from March 18 to May 12, 2020, with critical COVID-19 requiring invasive mechanical ventilation (IMV) for over 48 hours.

Interventions: None, due to study design.

Measurements and results: Data regarding positioning, positive end-expiratory pressure (PEEP), driving pressure, static lung compliance, and lowest daily arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2) ratio throughout the first 5 days of ICU admission were collected from daily ventilatory assessment charts. The median ICU length of stay was 11.3 days and median IMV duration was 9.5 days. The 28-day mortality was 12.1%. When comparing non-survivors and survivors, significant differences were found regarding Simplified Acute Physiology Score (SAPS) II (48.5, IQR 14.0 vs. 32.0, IQR 11.0, p=0.004), PaO2/FiO2 ratio before endotracheal intubation (101.3, IQR 22.5 vs. 174.1, IQR 9.5, p=0.01) and throughout ICU stay. Over 90% of patients were submitted to prone positioning. Use of low PEEP levels and maintenance of low driving pressures in patients whose overall compliance was low as possible.

Conclusions: Significant differences were found regarding SAPS II and PaO2/FiO2 ratios between survivors and non-survivors, eliciting further investigation as potential mortality predictors. With the second wave of the pandemic taking shape, sharing previous experience is crucial to further coordinate efforts internationally.

Authors: Mafalda Aguiar Mourisco, Filipa Resende Brochado, Filipe Silva Machado, Diana Moreira Dias, Ricardo Pinho, Paulo Reis Rodrigues

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


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


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


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