The effect of mild hypothermia therapy in the level of MMP-9 protein and the Marshall CT score in high risk traumatic brain injury


The effect of mild hypothermia therapy (34°-36°C) and alterations of matrix metalloproteinase-9 (MMP-9) were examined in 20 patients with high risk traumatic brain injury (TBI). The neurologic status was assessed using the Full Outline of UnResponsiveness (FOUR) score and the outcome using the Marshall CT score. The objective of this study was to determine serum MMP-9 level and the Marshall CT score. This research used a prospective randomized controlled study and was conducted in RD Kandou Hospital Manado. Patients with high risk TBI (the FOUR score ≤7) were randomized into two groups, with and without mild hypothermia therapy, and were investigated within 24 and 72 hours. The MMP-9 protein levels were estimated using enzyme-linked immunosorbent assay (ELISA). Different levels of these variables were compared in the two groups. The results showed that the level of MMP-9 protein significantly decreased (p<0.05) in the hypothermia group; however, there was no significant improvement of the Marshall CT score (p>0.05) within 24-72 hours. The study concluded that mild hypothermia therapy had a significant influence on the alteration of biomarkers rather than the alteration of anatomical imaging in high risk TBI patients.

Authors: Eko Prasetyo, Andi Asadul Islam, Mochammad Hatta, Djoko Widodo, Ilhamjaya Pattelongi

Decision making of tracheostomy and extubation outcomes in mechanically ventilated patients evaluated by logistic regression and decision tree analyses


Background: Most studies determining the predictors of extubation outcomes in patients with mechanical ventilation have not included high-risk populations who avoid extubation and undergo tracheostomy.

Objective: To evaluate predictors of extubation intolerance by analyzing patients regardless of whether extubation was attempted or not.

Design: Retrospective cohort study.

Settings: Mixed intensive care unit (ICU) of Kumamoto University Hospital.

Patients and participants: Medical data of 288 consecutive mechanically ventilated adults were collected. Initial outcomes of endotracheal tube treatment were classified as 1) successful extubation, 2) extubation failure, and 3) tracheostomy without attempting extubation. Clinical variables responsible for those outcomes were determined by logistic regression and decision tree analyses. We defined combined outcome of extubation failure and tracheostomy as extubation intolerance in the present study.

Results: Of 288 patients, 17 failed extubation and 37 opted for tracheostomy without extubation. Logistic regression analysis revealed that the significant predictors of extubation failure were weak cough strength, poor consciousness, and excessive airway secretion. The propensity score of extubation failure calculated by logistic regression analysis in the tracheostomy group was as high as that of extubation failure group. A decision tree to predict the outcomes was described by branching with consciousness, style of ICU admission, and volume of airway secretion.

Conclusions: The principle predictors of extubation intolerance were related to instability of airway patency, and the decision making of tracheostomy was shown to be appropriate. These statistical methods could reduce the selection bias of study subjects.

Authors: Susumu Hirosako, Hirotsugu Kohrogi, Katsuyuki Sagishima, Keisuke Sakai, Yohei Migiyama, Hidenobu Kamohara, Hiroaki Kawano, Yoshihiro Kinoshita

Incidence of CAUTI in a new integrated ICU/HD in Singapore over 1 year


Hospital-acquired infection worldwide has been associated with significant mortality and morbidity and unfortunately catheter-associated urinary tract infection (CAUTI) is known to be one of the commonest hospital-acquired infections.

A retrospective study was done to determine the incidence of CAUTI in the Intensive Care Unit/High Dependency (ICU/HD) in Ng Teng Fong General Hospital (NTFGH) since it was opened from 1 July 2015 to 31 July 2016. NTFGH Intensive Care Unit is an integrated ICU/HD unit that manages a combination of surgical, medical, trauma and cardiac patients. The inclusion criteria were patients catheterized and with urinary tract infections diagnosed in ICU/HD and also diagnosed with UTI within 48 hours of discharge from ICU/HD. The data was retrieved from hospital electronic database. The types of organisms and their resistant pattern to antibiotics were analysed.

A total of 3159 patients were admitted to the ICU/HD during this period. One hundred eighteen patients were diagnosed with urinary tract infections in general and out of this group 69 patients were noted to have CAUTI based on CDC criteria. The commonest organisms related to CAUTI were Escherichia coli and Klebsiella pneumoniae. These two organisms showed a similar pattern of establishing resistance to all the first line antibiotics used and they were ampicillin, amoxicillin-clavulanic acid and cephalosporins. Though the usage of quinolones, sulfamethoxazole-trimethoprim and gentamicin were low, these organisms have also established resistance to these 3 antibiotics. Enterococcus fecalis was the next commonest organism and was often associated with the presentation of diarrhea. Other organisms including Pseudomonas, Proteus, Enterobacter, Morganella, Citrobacter, Burkholderia and Staphylococcus were sporadically reported.

The common risk factors for developing CAUTI noted were surgical elderly male patients with diabetes and a history of obstructive UTI.

A committee involving a team from ICU has been set to review the current indwelling urinary catheter bundle and rectify the problems and implement new measures to reduce the incidence of CAUTI.


A randomized pilot study of parenteral glutamine supplementation in severe sepsis


Purpose: Glutamine depletion can occur in critically ill patients and parenteral glutamine supplementation can have beneficial effects on critically ill patients by preserving gut barrier and improving immune function. We wanted to examine the effect of glutamine supplementation in a cohort of severe sepsis patients admitted to a hospital in South East Asia.

Design: A single center, randomized, doubleblinded, placebo-controlled, pilot study. The primary outcome was 28-day mortality. Secondary outcomes were ICU length of stay (LOS), hospital LOS, duration of mechanical ventilation and occurrence of new infections. Disease severity on admission was assessed by Sequential Organ Failure Assessment (SOFA) score.

Setting: Medical intensive care unit (MICU) of Changi General Hospital, which is a 1000-bedded teaching hospital in Singapore.

Patients and participants: Patients admitted to the MICU for severe sepsis with ≥2-organ dysfunction.

Interventions: In the intervention arm, intravenous glutamine was given for 5 days at a dose of 0.5 g/kg body weight/day. The placebo was normal saline.

Measurements and results: Thirty-nine patients were randomized to receive glutamine (n=19) or placebo (n=20). The glutamine group exhibited milder disease severity than placebo (median SOFA score 8 vs 11, p=0.038). There was no overall difference in 28-day mortality between the glutamine and placebo (42% vs 15%, p=0.06). When adjusted for disease severity, the glutamine arm had 5.6 times higher death rates (95% CI 1.1-30.2, p=0.044). The glutamine group had lower incidence of new infections (0% vs 30%, p=0.02). There was no difference in ICU LOS, hospital LOS and the duration of mechanical ventilation.

Conclusions: Parenteral glutamine may increase mortality risk in ICU patients with severe sepsis while reducing the risk of new infections.


A comparison of NSS vs balanced salt solution as a fluid resuscitation and impact of fluid balance on clinical outcomes in pediatric septic shock


Septic shock is a common condition affecting children worldwide. Initial resuscitation with crystalloid fluid is the first step in treatment of septic shock. However, there is increasing concern about side effects of using normal saline. Our objective was to compare the effectiveness of balanced salt solution vs 0.9% normal saline solution (NSS) on decreasing morbidity and mortality in pediatric septic shock. This was a prospective observational study enrolled septic children aged 1-15 years treated at the Department of Pediatrics, King Chulalongkorn Memorial Hospital. They were given fluids resuscitation according to Surviving Sepsis Campaign (SSC) guidelines. Thirty-five sepsis children were enrolled, 20 received normal saline as first line fluid resuscitation and 15 received balanced salt solution (Ringer lactate solution [RLS]) as first line fluid resuscitation. Baseline characteristic of both groups were similar. RLS group received significantly less fluid resuscitation at 24 and 48 hours compared to NSS group (134.3±42.9 vs 171.3±49.5; p=0.02, 236.9±75.7 vs 313.1±115.3; p=0.03). Moreover, RLS group had significantly less metabolic acidosis and better base excess at 6 hours and 24 hours compared to NSS group (2.5±4.1 vs -3.7±4.1; p<0.001, 3.4±3.2 vs -1.2±3.9; p=0.03). There was no statistically significant difference in mortality between two groups (15% [n=3] NSS, 6.7% [n=1] RLS).

Conclusion: Using balanced salt solution for resuscitation decreased metabolic acidosis and tended to decrease fluid intake and fluid accumulation.


Blood plasma plasmalogens and fatty acids in multiple organ dysfunction syndrome


Introduction: Changes in fatty acid composition as well as in a level of blood plasma plasmalogens in cases of various pathological conditions are evidences of lipid metabolism disorders and can indicate their reasons and degree. The objective of this study was to analyze fatty acids and plasmalogens of blood plasma in patients with multiple organ dysfunction syndrome (MODS).

Methods: Fatty acid ethyl esters and diethyl acetals of fatty aldehydes obtained during sample preparation were analyzed by capillary gasliquid chromatography.

Results: Marked changes in the plasma fatty acid composition and plasmalogen levels in pa tients with MODS were detected.

Conclusions: Based on the detected significant reduction in the plasmalogen levels of blood plasma, a conclusion was made about possible presence of peroxisome dysfunctions in patients with MODS. Peroxisome dysfunction may be one of the reasons of violation of detoxification processes, fatty acids oxidation disorder, prolongation and intensification of the inflammatory process, neurological disorders, and decreased blood antioxidant capacity. The assumption was made about an important role of fatty acids in disturbance of systemic hemodynamics, assessment of a degree of lipid metabolism disorders and activity of сatabolic response.


The effect of selective COX-2 inhibitor on blood glutamate in moderate traumatic brain injury


Head injury is the leading cause of death and disability in adolescence, children and the elderly. Post-traumatic brain damage is determined by combination of primary and secondary head injuries. Neuroinflammation is one mechanism of secondary brain injury. Selective cyclooxygenase (sCOX-2) inhibitors are drugs commonly used in treatment of postoperative pain but also possess an anti-inflammatory effect. The aim of this study is to determine the role of sCOX-2 inhibitors to inhibit the inflammatory processes in patients with head injury by measuring the glutamate levels.

This is a double blind randomized controlled study involving patients with moderate head injuries who underwent surgery at Dr. Hasan Sadikin Hospital Bandung since December 2013 until December 2015. After obtaining study approval from the Research Ethics Committees of School of Medicine Padjadjaran University/Dr. Hasan Sadikin Hospital, samples were clustered randomly into 5 groups: the control group, the COX2-group I (given sCOX-2 inhibitor once/day), the COX2-group II (given sCOX-2 inhibitor twice/day), the COX2-group III (given sCOX-2 inhibitor thrice/day), and the COX2-group IV (given sCOX-2 inhibitor four times/day), and each group consisted of 6 patients. All patients received standard therapy as recommended by Brain Trauma Foundation Guidelines 2007 as well as performed monitoring of blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature and blood sugar during pre and postoperative stages. The data were analyzed using paired samples t-test and one-way Anova, which p<0.05 is considered as statistically significant.

Results showed that there was a significant reduction in glutamate level in COX2-group II with the p-value of 0.035. The study concluded that sCOX-2 inhibitor has a brain protective effect by lowering the levels of glutamate as neuroinflammatory biomarkers in patients with head injury.


Albumin level as a predictor of shock and recurrent shock in children with dengue hemorrhagic fever


Background: The severity of dengue hemorrhagic fever (DHF) can be seen from bleeding and plasma leakage manifestations. Albumin level is one of the markers of plasma leakage in dengue infection. Whether albumin can be used as a predictor of shock in DHF patients or of recurrent shock in dengue shock syndrome (DSS) patients still need to be further evaluated.

Objective: To determine serum albumin level as a predictor of shock in DHF and of recurrent shock in DSS.

Design: A cohort prospective study.

Setting: Department of Child Health, Prof. Dr. RD Kandou Hospital, Manado, Indonesia.

Patients and participants: Sixty-seven DHF patients and 58 DSS patients aged 1- to 14-yearold were enrolled in our study. Sampling was done with consecutive sampling method. The inclusion criteria were patients diagnosed with DHF/DSS based on World Health Organization (WHO) criteria (2011). The exclusion criteria were patients who received corticosteroids, blood transfusion, albumin infusion and patients with severe malnutrition. The dependent variables were shock and recurrent shock. The independent variable was serum albumin level. The relation between serum albumin level and shock or recurrent shock were analyzed using logistic regression test, power 0.80, α 0.05 and was significant if p<0.05. We used receiver operating characteristic (ROC) curve to determine prognostic factors. Data was analyzed using software SPSS v 21.0.

Results: There was significant correlation between albumin level and shock in DHF patients (p=0.0001, area under the curve (AUC) 0.865, cut-off 3.05, odds ratio (OR) 17.4, sensitivity 79%, specificity 81%), but there was no correlation between albumin level and recurrent shock in DSS patients.

Conclusions: Serum albumin level can be used as a predictor of shock in DHF patients but it cannot be used as predictor of recurrent shock in DSS patients.


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


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

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

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

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

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

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

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


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


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

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

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

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

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

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


Prognostic value of serum cholinesterase activity in the septic shock due to bacterial infections

Context: Kinetics of SChE activity analyses, in our knowledge, was not previously studied in the prediction of prognosis of patients with septic shock.
Objective: We aimed to analyse kinetics of SChE activity in 4 patients with septic shock.
Materials and methods: Prospective study.
Results: The kinetics analyses of SChE activity showed that SChE activity was correlated with the prognosis (decrease in deads and increase in survivors).
Discussion and conclusion: The kinetics of SChE activity can be used as a biomarker to
predict the prognosis of patients with septic shock.


The association between delta shock index and mortality in children with shock

Background: Shock remains one leading cause of morbidity and mortality in hospitalized children. Delta shock index is a simple tool to assess and evaluate shock.
Objective: To investigate whether delta shock index might be related to mortality in children with shock.
Methods: Prospective cohort study.
Setting: Emergency Room (ER) and Pediatric Intensive Care Unit (PICU) of Sanglah University Hospital, Bali from March 2015 to March 2016.
Patients and participants: Children aged 1- month to 12-year-old that were diagnosed with shock during admission or during hospitalization. Subjects were divided into delta shock index (DSI)≤0 group and DSI>0.
Results: From March 2015 to March 2016 a total of 80 subjects were recruited. There were 40 cases with DSI≤0 and 40 cases with DSI>0. Mortality was found in 28 (70%) patients with DSI≤0 group. Chi-square analysis showed significant association between DSI and mortality (RR 1.9, 95%CI:1.2-2.9; p=0.004). Survival analysis showed median time survival was 5 days for the group with DSI≤0 and 7 days for the group with DSI>0 (log-rank 0.03). Cox regression analysis showed that DSI≤0 (RR 1.895, 95%CI:0.989-3.623; p=0.037) and age (RR 0.988, 95%CI:0.979-0.997; p=0.015) were risk factors for mortality in children with shock.
Conclusion: DSI≤0 was associated with mortality in children with shock.


A randomized controlled trial: Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution

Background: Hyponatremia is a condition that may cause dangerous clinical manifestations. Diarrhea with dehydration is one of the most common causes for hyponatremia. Intravenous hypotonic fluid is used for children with moderate dehydration and isotonic Ringer lactate is used for severe dehydration in several therapy guidelines for diarrhea.
Aims: To investigate the difference in changes of serum sodium levels between rehydration therapy with standard hypotonic solution and balanced solution for children with diarrhea and dehydration.
Design: Randomized controlled clinical trial.
Setting: Emergency unit in Dr. Soetomo General Hospital, Surabaya, Indonesia.
Patients: Forty children aged between 3 months to 12 years old who were diagnosed with diarrhea with moderate dehydration based on Haroen Noerasid’s clinical criteria. Patients were randomly assigned into two groups: standard hypotonic solution therapy group (n=21) and balanced solution therapy group (n=19).
Interventions: Children in the standard therapy group received standard hypotonic solution (Na+ 50 mmol/L), while the other group received balanced solution (Na+ 145 mmol/L) as the main fluid during rehydration therapy.
Results: The mean initial serum sodium levels in the standard hypotonic solution and balanced solution group were 141 mmol/L and 141.4 mmol/L, respectively. The difference was found to be not statistically significant. There was a statistically significant difference between the post rehydration mean serum sodium levels of the standard hypotonic (138.3 mmol/L) and balanced solution group (141.7 mmol/L). The mean reduction of serum sodium levels was 2.48 mmol/L in the standard hypotonic solution group and there was a mean increase of 0.37 mmol/L in the balanced solution group. We found clinically a not significant difference of symptoms of hyponatremia in this study. There was no seizure, neurological inpairment in both treatment groups before and after rehydration.
Conclusions: There were difference changes in serum sodium levels post rehydration therapy by using two different solutions. Balanced solution was more stable and a safer choice to protects against hyponatremia.

A randomized controlled trial- Changes of serum sodium levels in children with diarrhea moderate dehydration receiving rehydration therapy with standard hypotonic solution or balanced solution


Prediction of colloid osmotic pressure from albumin and/or hemodynamics in pigs undergoing hemorrhagic shock

Background and purpose: Colloid osmotic pressure (COP) is strongly affected during by hemorrhagic shock (HS) and imbalances may result in pulmonary and systematic oedema. Measurement of COP is therefore crucial in order to monitor changes and to react to critical levels. The aims of this study were to examine the time-course effects on COP and albumin in pigs undergoing controlled HS, and to investigate whether albumin and/or hemodynamic parameters are relevant predictors of COP during HS.
Methods: 18 pigs randomly assigned in a blinded manner to one of three groups. Group 1: sham (n=4); group 2: hemorrhage control (n=7) and group 3: hemorrhage + adenosine, lidocaine and Mg2+/adenosine, lidocaine (ALM/AL) (n=7). COP was measured using a commercially available oncometer.
Results: Group 2 experienced the greatest change in absolute and relative COP-values during the experiment, while group 1, as expected, experienced the smallest change. Strong correlations were seen between COP and albumin for group 2 (0.84, p<0.001) and for group 3 (0.82, p<0.001), whereas moderate to negligible correlations were seen between COP and the hemodynamic parameters. Conclusion: Pigs subjected to HS compensated unexpectedly well compared to pigs not exposed to HS (sham). It is possible to predict COP from albumin, which may be clinically relevant in situations where an oncometer is not accessible. Further studies are needed if these findings are to be transferred to humans.


Antimicrobial resistance patterns of Staphylococcus aureus in the intensive care unit at a tertiary hospital

Purpose: The objective of the present study is to determine the pattern of antimicrobial resistance of Staphylococcus aureus (S. aureus) in the Intensive Care Unit at a tertiary hospital in Mexico.
Methods: 1,511 cultures in general surgery, internal medicine, neurosurgery and the ICU were analyzed, the sample pool was limited to ICU patients and out of those, only samples positive for S. aureus were included, meticillin resistance was confirmed.
Results: Of a total of 1,511 samples, 206 (13.63%) were culture positive for S. aureus. In the ICU, antimicrobial resistance to beta-lactams (penicillin, ampicillin, cephalothin, cefotaxime, cefazolin, amoxicillin/Ac. clavulanate and imipenem) averaged 73.52%; for clindamycin was 65.12%; ciprofloxacin 59.09%, erythromycin 65.31% and for vancomycin was 6.52%.
Conclusions: The present study showed a high incidence of MRSA in an Intensive Care Unit at a tertiary hospital.

Antimicrobial resistance patterns of Staphylococcus aureus in the intensive care unit at a tertiary hospital