Effects of N-acetylcysteine on high-sensitive C-reactive protein level and wall motion score index after ST-segment elevation myocardial infarction and fibrinolytic therapy: A randomized trial


Objective: To determine the effect of N-acetylcysteine (NAC) on the high-sensitive C-reactive protein (hsCRP) level and wall motion score index (WMSI) in patients with ST-segment elevation myocardial infarction (STEMI) treated with fibrinolytic therapy.

Methodology: We performed a randomized pre-post study in consecutive patients who received fibrinolytic therapy for STEMI at Dr. Moewardi Hospital from July through August 2018. Patients were randomly allocated to receive NAC 600 mg 3 times daily for 3 days (treatment group) or no NAC (control group). Patients underwent pre- and post-treatment hsCRP measurement and echocardiographic examination with calculation of the WMSI. Pre- and post-therapy differences in clinical characteristics were analyzed within and between groups using independent sample t-, Mann-Whitney, paired t-, and Wilcoxon tests as appropriate.

Results: Thirty-two patients were analyzed. The control and treatment groups included 15 (mean age 58.27±8.07 years) and 17 (mean age 55.24±10.19 years) patients, respectively. There were significant between-group differences in hsCRP levels (p=0.001) and WMSIs (p=0.005) after therapy. In the control group, the median post-therapy hsCRP and WMSI were 151.50 mg/l (range 42.50-285.20) and 1.3 (range 1.1-1.7), respectively, compared to 14.90 mg/l (range 3.60-266.80) and 1.2 (range 1.0-1.5), respectively, in the treatment group.

Conclusion: Patients with STEMI who received NAC (600 mg 3 times daily for 3 days) in addition to fibrinolytic therapy had lower post-intervention hsCRP levels and WMSIs than patients who received fibrinolytic therapy alone. These findings will provide a therapeutic option for the successful management of patients with AMI.

Authors: Trisulo Wasyanto, Savithri Indriani, Ahmad Yasa

Intravenous thiamine as an adjuvant therapy for hyperlactatemia in septic shock patients


Objective: To assess the effectiveness of intravenous (IV) thiamine in reducing hyperlactatemia in septic shock patients.

Design: Prospective, randomized controlled trial.

Setting: General intensive care unit (GICU), Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur.

Patients and participants: Adult patients with septic shock and hyperlactatemia (lactate ≥2 mmol/l).

Interventions: IV thiamine 200 mg thrice daily for 3 days.

Measurements and results: A total of 72 patients were recruited into the study. Seven patients died within 24 hours of study commencement and were dropped out. Patients were randomized into the thiamine group (TG) who received IV thiamine 200 mg diluted in 50 ml of normal saline, or placebo group (PG) who received 50 ml of normal saline infusion over 30 minutes. Arterial blood lactate samples were collected at time of enrolment, after 6, 12, 18, 24, 48, and 72 hours of study drugs administration. Relative lactate changes over 24 hours, duration of weaning off vasopressors, Sequential Organ Failure Assessment (SOFA) score changes over 72 hours, ICU length of stay (LOS) and mortality rates were compared between groups. There were no significant differences in the relative lactate changes (TG: 37.5% [4.7-59.1] vs PG: 47.8% [29.1-70.7], p=0.091), duration of vasopressors being weaned off (TG: 75.5 [48.0-131.25] vs PG: 88.0 [48.0-147.0]), SOFA score changes (TG: 3.0±3.41 vs PG: 2.7±3.3), ICU LOS (TG: 5.0 [4.0-11.0] vs PG: 6.0 [3.0-12.0]), and ICU mortality rate (TG: 14 [43] vs PG: 12 [37]). Multivariate logistic regression test showed that baseline lactate level was an independent predictor for mortality (p=0.044).

Conclusion: Intravenous thiamine did not show significant improvement in relative lactate changes, time for shock reversal, SOFA scoring, ICU LOS, and mortality rate in septic shock patients with hyperlactatemia. However, baseline lactate level was shown to be an independent predictor for ICU mortality.

Authors: Nur Fazlina Harun, Saw Kian Cheah, Aliza Mohamad Yusof, Chee Lan Lau, Azlina Masdar, Siti Nidzwani Mohamad Mahdi, Nurlia Yahya, Norma Mohamad, Raha Abdul Rahman

Comparison of outcome between percutaneous dilatation tracheostomy and surgical tracheostomy in Intensive Care Unit of Dr. Wahidin Sudirohusodo Hospital Makassar


Percutaneous dilatation tracheostomy (PDT) has been widely used in Indonesia, yet no study to evaluate the outcome of PDT compared to surgical tracheostomy (ST) is available.

Objective: This study was aimed to evaluate the use of PDT in Indonesia.

Design: Non-randomized comparative retrospective study.

Setting: Intensive Care Unit of Wahidin Sudirohusodo Hospital Makassar.

Patients: Eighty-four patients aged 15 to 90 years, undergone tracheostomy during 2016 to 2017 were evaluated.

Measurements and results: Samples were evaluated in terms of surgical duration, blood loss volume, mortality, and complication rates such as post-operative bleeding, pneumothorax, subcutaneous emphysema, stomal infection, tracheal stenosis/malacia, and unintended fistula formation. Collected data were analyzed with SPSS version 22. Mean operative duration of PDT (18.3 minutes) were significantly faster than ST (40.2 minutes) (p<0.05), accompanied by significant reduction of mean blood loss 13.6 ml compared to 21.1 ml in ST group (p<0.05). A total of 9 complications (18.8%) found in ST group and 5 (13.9%) in PDT group, with stomal infection was the most common complications. Mortality rate were 52.8% in PDT group and 45.8% in ST group (p>0.05), none associated with the procedure itself.

Conclusion: It is suggested that PDT is a superior technique in placement of tracheostomy canula.

Authors: Syafri K. Arif, Andy Setiawan, Hisbullah, Faisal Muchtar, Haizah Nurdin

Short-term complications of ultrasound-guided bedside peripherally inserted central catheter in the Intensive Care Unit: 1 year experiences


Objectives: Critically ill patients in the intensive care unit (ICU) need central catheter for various reasons, such as long-term intravenous access, nutrition, antibiotic usage, or chemotherapy. Generally, peripherally inserted central catheter (PICC) lines are the most commonly used type of intravenous access meant for long-term use. But, moving critically ill patients from the intensive care unit to the interventional radiology room (IRR), where PICC installation is usually performed, can disrupt ongoing critical care and may be in dangerous situation. Recently, several articles have reported the successful clinical implementation of bedside PICC installation under ultrasound (US) guidance. We aimed to evaluate and report the 1 year experiences of bedside PICC installation under US guidance in ICU by analysis short-term complications.

Methods: We performed a retrospective cohort study of 123 PICCs placed in adult ICU at a tertiary care academic medical center between October 2017 and September 2018. The data were analyzed to identify short-term complications, such as malposition of catheter tip, infection, and occlusion.

Results: Among 123 PICCs, 52 cases were performed in the IRR and 71 cases were performed in the ICU. The overall complications were in 18 cases (14.6%). Malposition of catheter tip was found in 12 cases (9.8%), infection was found in 4 cases (3.3%), occlusion was found in 2 cases (1.6%). Complication rate was higher in the ICU group (18.3%) than the IRR group (9.6%). Malposition was found in 11 cases in the ICU group and 1 case in the IRR group. Infection was found in 2 cases in both groups. Occlusion was found in 1 case in both groups.

Conclusions: The incidence of malposition of catheter tip as short-term complication is higher in the case of performing bedside PICC installation under ultrasound in ICU than in IRR.

Authors: Se Heon Kim, Young Hoon Sul, Yook Kim, Joong Suck Kim, Moon Sang Ahn

Sodium bicarbonate buffering for metabolic acidosis does not hasten hemodynamic improvement in septic shock: a retrospective analysis of a 5-year period


Objective: Severe metabolic acidosis often occurs in the setting of septic shock and hemodynamic collapse. Acid buffering agents such as sodium bicarbonate are often used to improve acidosis, although the hemodynamic benefit of improving the serum pH is uncertain and has been evaluated only in a few small clinical studies.

Design: A retrospective cohort of patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate.

Setting: A single-center mixed medical-cardiac-surgical intensive care unit.

Patients and participants: 21 patients with vasopressor-dependent septic shock who were treated with sodium bicarbonate. Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate served as a matched control group.

Interventions: The primary endpoint was the change in norepinephrine equivalent (NEEq) dose at 24 and 48 hours after initiation of sodium bicarbonate when compared to non-sodium bicarbonate treated patients. Secondary outcomes included: hospital mortality, the impact of hypocalcemia on vasopressor requirements, and the impact of hypercapnia on vasopressor requirements in sodium bicarbonate treated patients.

Measurements and results: Patients with vasopressor-dependent septic shock who were not treated with sodium bicarbonate had no difference in the decline of vasopressor requirements than those administered sodium bicarbonate at 24 hours (0.09 μg/kg/min; 95% CI, [-0.23, 0.05], p=0.19) and at 48 hours (0.04 μg/kg/min; 95% CI [-0.11, 0.18], p=0.60). In patients with pH≤7.15, there was no difference in the change in NEEq dose between sodium bicarbonate treated or non-bicarbonate treated patients at 24 hours (0.05 μg/kg/min, 95% CI, [-0.09, 0.11], p=0.69) or at 48 hours (0.19 μg/kg/min, 95% CI, [-0.52, 0.14], p=0.17).

Conclusions: Administration of sodium bicarbonate did not improve vasopressor requirements at 24 or 48 hours, even in patients with a pH less than 7.15. Mortality and vasopressor needs are high in patients with pH less than 7.15 and unaffected by sodium bicarbonate administration.

Authors: John H. Ferguson, Maurice M. Otterstetter, Nicholas JK Tranchida, James DeFoe

Predictors of perceptions of patient safety culture and frequency of event reporting by critical care nurses in Oman: a model-building approach


Objectives: This study was conducted to identify the predictors of critical care nurses’ perceptions of patient safety culture and the frequency of event reporting.

Methods: A cross-sectional study design was used. Patient safety culture was assessed using the Hospital Survey on Patient Safety Culture, which was completed by 270 critical care nurses working in two hospitals in Oman.

Results: The results revealed that teamwork within units had the highest positive score (91.8%), followed by organisational learning and continuous improvement (86.3%) and feedback and communication about errors (77.7%). Regression analysis showed that teamwork within units, supervisor/manager expectations and actions promoting patient safety, organisational learning and continuous improvement, management support for patient safety, feedback and communication about errors, teamwork across units, staffing, hospital handoffs and transitions, and patient safety grade were all predictors of the overall perception of patient safety culture among critical care nurses in Oman (R2=0.462, adjusted R2=0.186; F=7.83, p<0.0001). Regression analysis showed that openness in communication, income, non-punitive response to errors, organisational learning and continuous improvement, and feedback and communication about errors were predictors of the frequency of events reporting among critical care nurses in Oman (R2=0.24, adjusted R2=0.043; F=3.41, p<0.0001).

Conclusion: Patient safety culture is an important indicator of the quality of care, and represents one of the key performance indicators in the healthcare setting.

Authors: Qasim Al Ma'mari, Loai Abu Sharour, Omar Al Omari

Eosinopenia as an indicator for organ dysfunction in septic patients


Sepsis is one of the most common causes of morbidity and mortality in intensive care unit (ICU).

Objective: To determine the possibility of eosinophil as indicator for organ dysfunctions in sepsis patients and septic shock patients in ICU.

Design: Prospective.

Setting: Intensive care unit (ICU) Wahidin Sudirohusodo Hospital, Makassar.

Participants: Adult sepsis patients admitted to ICU from October to December 2018.

Measurement: Eosinophils count and Sequential Organ Failure Assessment (SOFA) scores were assessed within 24 hours and after 72 hours after patients admitted in ICU. The patients were categorized into non- and organ dysfunction groups based on SOFA scores after 72 hours. Outcomes of the patients then evaluated at day 7.

Results: Thirty four sepsis patients participated in the study. The mean of SOFA scores between non- and organ dysfunction groups were not different within 24 hours after admission but then showed a difference after 72 hours (p=0.558 and p<0.001, respectively). In contrast with non-organ dysfunction patients, after 72 hours the eosinophil count in organ dysfunction group decreased (from 0.51 to 0.15 cells/µl). There was a negative correlation between eosinophil count and SOFA scores at 72 hours (p=0.043; rho: -0.350). In discriminating non-organ dysfunction and organ dysfunction groups, the area under the receiver operating characteristic curve was 0.714. Eosinophils at 0.5 cells/µl (eosinopenia) yielded a sensitivity of 92.8%, a specificity of 66.6%, a positive predictive value of 92.8%, and a negative predictive value of 66,6%.

Conclusion: Eosinopenia levels might be used as an indicator for organ dysfunction in critically ill patients, including sepsis patients, in area where laboratory facility is limited.

Authors: Syafri Kamsul Arif

Do Asian physicians manage hypertensive crisis properly? A Southeast Asia survey analysis


Purpose: Hypertension remains a common cause of morbidity and mortality worldwide, and proper management can prevent death. Over the last few decades, several changes in definitions, clinical manifestations, and management have occurred. We aimed to investigate the extent of knowledge about these changes, as the pertain to acute elevations of blood pressure among physicians in Southeast Asia.

Methods: A cross-sectional survey was created and validated. The survey included 25 questions about the definitions of hypertensive urgencies and emergencies, clinical presentations, ideal rate of blood pressure reduction, and other questions. Surveys were distributed at the Asia Pacific Symposium held in Indonesia in August 2017. Descriptive analysis was conducted using IBM SPSS Statistics™ version 25.0 (IBM Corporation, Armonk, NY).

Results: A total of 145 surveys were completed by physicians from India, Indonesia, South Korea, Philippines, Singapore, and Sri Lanka. Of them, only 49.6% (n=72) knew the normal blood pressure cut-off limits, and 19.3% (n=28) did not recognize the differences between hypertensive urgencies and emergencies. Moreover, 53.7% (n=78) of respondents was not aware that hypertensive urgency can be completely asymptomatic. Sixty-four point eight percent (n=94) indicated that acute cerebrovascular accidents were the most common end-organ damage from hypertensive emergencies. In addition, only 44.1% (n=64) were aware of the ideal rate of blood pressure reduction, and 50.3% (n=73) considered sublingual nifedipine as an appropriate choice in hypertensive crisis management.

Conclusions: A significant percentage of physicians in Southeast Asia lack knowledge about hypertensive crisis definitions, clinical presentations, and management.

Authors: Abbas Alshami, Johanan Luna, America Avila, Salim Surani, Joseph Varon

Corticosteroids and gastrointestinal bleeding in critical care: a systematic review and meta-analysis


Background: Current belief suggests that patients receiving corticosteroids have an increased risk of bleeding from stress ulceration and that these patients should receive stress ulcer prophylaxis. This issue is important as many ICU patients receive corticosteroids and the pharmacologic agents used for stress ulcer prophylaxis are associated with adverse events.

Aim: The goal of this systematic review and meta-analysis was to compare the rate of clinically significant (overt) gastrointestinal (GI) bleeding in critically ill patients receiving corticosteroids versus placebo.

Methods: We searched PubMed, Embase, and the Cochrane database from inception through December 2018. In addition, the bibliographies of selected articles were reviewed for relevant studies and included if inclusion criteria were met. Included studies were randomized, placebo-controlled and blinded studies that compared treatment with corticosteroids for any indication in a patient population that included only ICU patients. Primary outcome of interest was rate of clinically significant GI bleeding in patients treated with corticosteroids versus placebo. Results were expressed as risk ratio (RR) with accompanying 95% confidence interval (CI). Heterogeneity, sensitivity analysis, and risk of bias were explored. In addition, we did a subgroup analysis according to the use of “low-dose” (<400 mg hydrocortisone or equivalent/day) versus “high-dose” corticosteroid.

Results: Thirty-five studies, which enrolled 16,659 patients, met inclusion criteria and were analyzed. Significant GI bleeding was recorded for 355 patients (overall rate of 2.1%). Summary data demonstrated no difference in the risk of GI bleeding between those treated with corticosteroids versus placebo (RR 1.08; 95% CI 0.88-1.33; p=0.46) with minimal heterogeneity between studies (Q statistic p=0.86, I2=0%). Similarly, there was no significant difference in the risk of GI bleeding in either the low (RR 1.04; 95% CI 0.78-1.38) or the high dose groups (RR 1.13; 95% CI 0.84-1.53) and in those studies at low risk of bias (RR 1.16; 95% CI 0.91-1.49) and those at a high risk of bias (RR 0.88; 95% CI 0.6-1.28).

Conclusion: This meta-analysis did not identify a clinically significant difference in the rate of overt GI bleeding in critically ill patients receiving corticosteroids as compared to placebo. The role of stress ulcer prophylaxis in these patients remains uncertain.

Authors: Paul E. Marik, Mit P. Patel, Joseph Varon

The effect of N-acetylcysteine on the myeloperxidase and Tei index in patients with acute myocardial infarction


Bacground: Myeloperoxidase (MPO) is a strong oxidant and toxic to microorganisms with excess production causing tissue damage. We aimed to determine the effect of N-acetylcysteine (NAC) 600 mg orally 3 times a day for 3 consecutive days on MPO levels and left ventricle myocardial performance index (LVMPI/Tei index) in ST elevation myocardial infarction (STEMI) patients treated with fibrinolytics.

Methods: Pre- and post-design, single blind experimental randomized trial, conducted on 32 patients with STEMI at Intensive Cardiovascular Care Unit (ICVCU). The subjects were divided into 2 groups: 17 patients received 600 mg t.i.d NAC for 72 hours and 15 controls. MPO levels before and after 72 hours and Tei index 72 hours after NAC therapy were measured. Statistical analysis of MPO level and Tei index were analyzed with SPSS 22. Tei index was measured using the pulsed wave Doppler (PWD) and tissue Doppler imaging (TDI).Results: NAC administration showed decrease in the marker of MPO (112.76±57.28 vs 180.40±69.03, p=0.001) and delta MPO (-50.15±46.62 vs 12.06±108.65) 72 hours after NAC therapy compared with control. NAC improved the LVMPI value compared to the control group. Tei index examination using PWD (0.39±0.11 vs 0.49±0.08, p=0.005) and that using TDI (0.41±0.08 vs 0.57±0.08, p=0.001) showed improved values for NAC administration than those with controls.Conclusion: NAC 600 mg orally 3 times a day for 3 consecutive days can reduce MPO levels and improve diastolic function by decreasing LVMPI values.

Authors: Trisulo Wasyanto, Ahmad Yasa, Nuka Meriedlona

The effect of oral N-acetylcysteine on galectin-3 and global longitudinal strain in patients with acute myocardial infarction


Objective: Galectin-3 (Gal-3) plays a big role in the development of cardiac fibrosis; however, its role in remodeling after acute myocardial infarction (AMI) has not received sufficient attention. Post-AMI measurements of global longitudinal strain (GLS) are beneficial in providing information about infarct area and remodeling. We aimed to determine the effect of N-acetylcysteine (NAC) on Gal-3 and GLS in AMI.

Design: This was a randomized, single-blind study with pre- and post-treatment evaluations performed from May 1 to August 31, 2018.

Setting: Dr. Moewardi Hospital, Indonesia

Patients: ST elevation myocardial infarction (STEMI) patients who received fibrinolytic therapy were randomly allocated to NAC and control groups.

Interventions: A total of 32 STEMI patients were administered fibrinolytic therapy (17 patients were administered standard therapy plus 600 mg NAC orally three times a day for 72 hours and 15 patients were administered standard therapy plus placebo as the control). Gal-3 samples were taken during admission and at 72 hours in both groups, while GLS measurement was only performed 72 hours after admission.

Measurements and results: Gal-3 levels in the NAC and control groups at admission were not significantly different; however, levels were significantly different after 72 hours (p=0.017). After comparing Gal-3 levels during admission and at 72 hours, the NAC group showed significant differences between Gal-3 levels at the time of admission and at 72 hours (p=0.0001); no difference was found in the control group. There were also significant intergroup differences in Gal-3 level changes (p=0.014). In the NAC group, a better and significantly different 72-h GLS value was obtained from that in the control group (p=0.023).

Conclusion: Supplementary therapy with NAC can reduce Gal-3 levels and GLS in AMI patients receiving fibrinolytic therapy.

Authors: Trisulo Wasyanto, Akhmad Jalaludinsyah, Ahmad Yasa

Correlation between zinc plasma level to inflammation response of patient with ventilator in pediatrics intensive care unit


Objective: Critical conditions arise when there is a threat or ongoing organ failure that disrupts the balance of the body's oxygen and physiological needs. Patients often require help, such as endotracheal intubation procedures, mechanical ventilation, and renal or liver replacement therapy, in place of impaired organ function. Usually, complications are more common in children than in adults. Zinc is one of the micronutrients that plays a vital role as an antioxidant and the role of defense immune modulators against systemic inflammatory response syndrome (SIRS). Outcome patient with ventilator depends on SIRS response to the disease. Meanwhile the study about zinc supplementation in Pediatric Intensive Care Unit (PICU) is limited. The main objective of this study was to look at the correlation of plasma zinc levels with inflammatory responses in children of 1-12 years old with ventilator in pediatric intensive care unit.

Design and setting: This study was prospective study in Sanglah General Hospital, Denpasar and was calculated by Pearson analysis to determine the correlation of variables plasma zinc with levels of pro-inflammatory cytokines interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) and continued by general linier model analysis.

Results: More than 70% sample was insufficiency zinc for the first 24 hours and after 72 hours, respectively. Correlation between plasma zinc and pro-inflammatory cytokines were TNF-α; p<0.001 r: -0.91, and IL-6; p=0.013, r: -0.48 in 24 hours, and IL-6; p>0.05 r: 0.011, and TNF-α; p<0.01 r: 0.659 in 72 hours.

Conclusions: There were significant correlation in TNF-α and IL-6 measurement between zinc plasma insufficiency with pro-inflammatory cytokines in the first 24 hours and significant correlation in TNF-α in 72 hours. Therefore, zinc supplementation in 72 hours from patient admission to PICU may have important role to reduce morbidity in PICU.

Authors: Dyah Kanya Wati, Lanang Sidiartha, Ketut Tunas, Andrie Setiawan

Lactic acid’s role in sodium hypertonic lactic solution as a neuroprotector measured from the level of ATP, MCT-1 and necrosis area in intracerebral hematoma rats model


Objective: To discover the role of hypertonic sodium lactate (HSL) as the energy source, which in turn will act as a neuroprotector, by measuring adenosine triphosphate (ATP) level, monocarboxylate transporter 1 (MCT-1) and the extent of the necrotic areas.

Design: This was an experimental study that used randomized post-test only control group design.

Setting: Experimental Animal Care Unit Universitas Gadjah Mada.

Patient and participant: 32 white mice of Rattus norvegicus.

Intervention: After the protocol of this study was approved by the research ethic committee, 32 rats were randomly divided into two groups: HSL group (n=16) and NaCl 3% group (n=16) as the control group. Both groups were anesthetized using conversion-dose pentothal.

Results: ATP level in HSL group was higher compared to the control group (p=0.031). MCT-1 in HSL group was also higher than the control group (p=0.010). Necrotic areas were less extensive in the HSL group than the control group (p=0.000). Lactate levels at minute 30 (T30) and minute 360 (T360) increased in the HSL group, while increasing in the control group up to T30, then decreased gradually until T360.

Conclusion: Exogenous lactate in solution has effect as a neuroprotective of brain in the intracerebral hemorrhage (ICH).

Authors: Hamzah, Nancy Margarita Rehatta, Tatang Bisri, Siti Chasnak Saleh, Arie Utariani

End-of-life care (EOLC) in Jordanian critical care units: Barriers and strategies for improving


Background: End-of-life care (EOLC) is a pivotal element of work in ICUs and for critical care nurses, thus, it is considered one of the top research priorities recently as number of admission ICUs increasing and high percentage of deaths also.

Objective: This study was conducted to explore the obstacles of EOLC and strategies for improvement from nurses' perception.

Methods: The questionnaire, that was developed by Beckstrand and Kirchhoff (2005), was used to collect data from 163 critical care nurses from different hospitals.

Results: Two hundred questionnaires were distributed. One hundred and sixty-three questionnaires were completed and returned with response rate 81.5%. The majority of the participants were male nurse 104 (63.8%), with bachelor degree 153 (93.9%), working in adult ICU 105 (64.4%), as bedside nurse 141 (86.5 %). The highest obstacles from the nurses’ perception were family and friends who continually call the nurse wanting an update on the patient’s condition rather than calling the designated family member for information (mean=4.07). Furthermore, the highest three supportive behaviors from the nurses’ perception were physicians agreeing about direction of patient care (mean=3.96), family members accept that patient is dying (mean=3.94), and family designating one family member as contact person for the rest of the family (mean=3.89).

Conclusion: As the number of deaths is increasing in critical care units, the needs to understand how the EOLC is provided in these units. Identifying obstacles and supportive behaviours will assist the stakeholders and policymakers to set the action plans for improving the quality of EOLC.

Authors: Loai Abu Sharour, Maha Subih, Omar Salameh, Mohammad Alrshoud

Electrical cardiometry for non-invasive cardiac output monitoring in children with dengue hemorrhagic fever and shock in comparison between referral and non-referral


Objective: Shock in dengue hemorrhagic fever (DHF) is mostly caused by plasma leakage. Hemodynamic monitoring is essential for improving the quality of management and the outcome. We sought to find the hemodynamic profile of dengue hemorrhagic fever children with shock.

Design: a cohort prospective study.

Setting: Pediatric Intensive Care Unit (PICU) at tertiary general hospital in Surabaya, Indonesia.

Patients and participants: Children <18-year-old admitted to the PICU with diagnosis DHF with shock.

Intervention: All patients underwent measurement of hemodynamic profile with electrical cardiometry ICON OsypkaTM after the first fluid resuscitation.

Measurements and results: There were 37 patients with DHF grade 3. All patients had normal blood pressure on first examination, with the mean of systolic and diastolic blood pressure were 82.5±9.21 mmHg and 51.8±16.32 mmHg, respectively. They had low stroke volume (66.7%), high heart rate (60.6%), low cardiac output (49%), and high systemic vascular resistance (55%). Mean resuscitation fluid volume was 35.30±31.99 ml/kg, where referral patient had significantly higher resuscitation fluid volume (49.45±39.46 ml/kg) than non-referral (19.75±0.60 ml/kg), p=0.002. Thoracic fluid content were significantly higher in referral (75%) than those in non-referral patients (16.7%), p=0.001.

Conclusion: After first fluid resuscitation, children with DHF grade 3 obtained normal blood pressure but still in hypovolemic state. Referral patients had higher fluid volume resuscitation and thoracic fluid content than those in non-referral.

Authors: Ira Dharmawati, Andri Kurnia Wahyudhi, Intani Dewi Syahti Fauzi, Arina Setyaningtyas, Dwi Putri Lestari, Neurinda Permata Kusumastuti, Abdul Latief Azis