Decision for early tracheostomy in respiratory failure of a paralyzed myasthenia gravis patient with sepsis-induced pneumonia: A case report.

INTRODUCTION: The neuromuscular condition myasthenia gravis (MG) can make treating sepsis-induced pneumonia more challenging. Since these patients risk respiratory failure, decisions about airway treatment, including tracheostomy, can be difficult. We report a case of a patient with sepsis and concurrent MG who underwent an early tracheostomy due to acute respiratory failure. PRESENTATION OF CASE: A 44-year-old woman with a history of MG presented to the emergency department with a stiff tongue, hypersalivation, limb paralysis and a phlegmy cough causing severe respiratory distress, aggravated by community-acquired pneumonia. A chest X-ray showed extensive infiltration and consolidation in the lower lobes. The patient was transferred immediately to the intensive care unit on mechanical ventilation. Despite initial treatment with antibiotics and respiratory support, her mental and respiratory status deteriorated rapidly. Given the risk of myasthenic crisis, sepsis and impending respiratory failure, with anticipated lengthy ventilator utilization and hospitalization, a multidisciplinary team decided to perform an early tracheostomy. DISCUSSION: The early tracheostomy procedure was carried out securely on the third day of hospitalization. This allowed for better pulmonary hygiene, adequate ventilation, airway clearance and rehabilitation therapy. The family contributed to stoma care and breathing exercises. The patient's respiratory condition steadily improved over the following weeks. The cough reflex remained well, and mechanical ventilation was gradually weaned off. CONCLUSION: Early tracheostomy in a paralyzed MG patient with sepsis-induced pneumonia can improve clinical outcomes and optimize airway management.

Preoperative Fasting of Eight Hours Provide Better Gastric Emptying: Ultrasound Assessment of Gastric Volume.

BACKGROUND: Preoperative fasting is a common practice to decrease perioperative aspiration risk. The American Society of Anesthesiologists (ASA) recommends preoperative fasting of 8 hours after a full meal. ASA preoperative fasting recommendation is based on the Western diet. A typical Western diet has a higher fat content than Asian standard solid meals. This study aimed to analyze intragastric volume with ultrasound after 6-hour and 8-hour fasting after an Asian traditional solid meal. METHODS: This cohort study recruited 37 subjects from January to February 2019. Subjects were patients scheduled for elective non-digestive surgery and planned for preoperative fasting of 8 hours. Before preoperative fasting, all subjects consumed standard Asian meals. We performed an ultrasound of the gastric antrum during the relaxation phase after two contractions. After a good image was acquired, the cross-sectional area and gastric volume (GV) were calculated. GV was grouped based on a border value of 1.5 mL/kg. RESULTS: GV 6 hours after solid intake was 30.93 (1.60-205.25) mL, and GV 8 hours after solid intake was 16.34 (0.73-62.49) mL (P = 0.002). After 6 hours, 5.4% of the subjects had a GV above 1.5 mL/ kg, while after fasting for 8 hours, the GV of all subjects was below 1.5 mL/kg. Age was correlated moderately and negatively with the GV of 6 hours and 8 hours fasting (P < 0.001, correlation coefficient = -0.610, and P < 0.001, correlation coefficient = -0.580). CONCLUSION: Intragastric volume 8 hours after a standard Asian meal intake was lower than 6 hours after a traditional Asian meal.

Hemoperfusion techniques using Jafron HA330 cartridge combined with BBraun Dialog+ dialysis machine in patient with coronavirus disease 2019 pneumonia and septic shock: a case report.

BACKGROUND: The use of hemoperfusion for cytokine removal and inflammatory mediators is increasingly intense, especially in coronavirus disease 2019 patients who are already known to the general public for having cytokine storms. However, we have known about these cytokine storms for a long time in the critical care world. One of the modalities to remove cytokines is to use filtration and adsorption techniques with continuous renal replacement therapy. The use of continuous renal replacement therapy is usually constrained by its very high cost compared with standard care, especially in Indonesia, where health costs are covered by national health insurance. In this case, we use hemodialysis and hemoperfusion, using a dialysis machine, which is more cost-effective and easy to use. CASE PRESENTATION: We used the Jafron HA330 cartridge, modified for the BBraun Dialog+ dialysis machine. This case report presents an 84-year-old Asian man with septic shock due to pneumonia, congestive heart failure, and acute chronic kidney disease accompanied by fluid overload. After undergoing hemodialysis and hemoperfusion separately, there was a gradual and significant clinical improvement. Clinical indicators, including the vasopressor inotropic score and infection markers, should all be considered when deciding whether to begin hemodialysis and hemoperfusion. CONCLUSION: In general, using hemoperfusion to treat septic shock patients can reduce the length of stay in the intensive care unit, and morbidity and mortality.

Sudden life-threatening laryngeal edema in pregnancy: a case report.

BACKGROUND: Severe laryngeal edema during pregnancy is uncommon but can be encountered, particularly in patients with preeclampsia accompanied by other comorbidities. Careful consideration must be given to balance the urgency of securing the airway with the safety of the fetus and the patient's long-term health consequences. CASE PRESENTATION: A 37-year-old Indonesian woman was brought to the emergency department at 36 weeks gestation due to severe dyspnea. Her condition worsened a few hours later during intensive care unit admission, with tachypnea, decreased oxygen saturation, and inability to communicate, necessitating intubation. Due to the edematous larynx, we could only use 6.0-sized endotracheal tube. The use of a small-sized endotracheal tube was expected to be short-lived, so she was considered for tracheostomy. Nevertheless, we decided to perform a cesarean section first after lung maturation because it would be safer for the fetus, and laryngeal edema usually improves after delivery. Cesarean section was performed under spinal anesthesia for the safety of the fetus, and 48 hours after delivery, she underwent a leakage test with a positive result, so extubation was performed. Stridor was no longer audible, breathing pattern was within normal limits, and vital signs were stable. The patient and her baby both recovered well with no long-term health consequences. CONCLUSION: This case demonstrates that unexpected life-threatening laryngeal edema can occur during pregnancy, in which upper respiratory tract infections may trigger it. The decision between conservative and aggressive immediate airway management should be made with careful consideration of securing the patient's airway, the safety of the fetus, and the patient's long-term health consequences.

Assessing clinical reasoning in airway related cases among anesthesiology fellow residents using Script Concordance Test (SCT).

INTRODUCTION: Clinical reasoning is a core competency for physicians. In the field of anesthesia, many situations require residents to use their clinical reasoning to make quick and appropriate decisions such as during emergency airway cases. The Script Concordance Test (SCT) is a test developed in recent years and validated that objectively assess clinical reasoning ability. However, studies involving SCT to assess clinical reasoning in airway management is scarce. AIM: To evaluate SCT in assessing clinical reasoning for airway management in anesthesiology residents. METHOD: A cross-sectional study involving residents and anesthesiology consultants from the Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia was conducted to complete SCT. A panel of five anesthesiology consultants with more than 15 years of work experience constructed 20 SCT vignettes based on prevalent airway cases in our center from the past 10 years. Each SCT has three nested questions, with a total of 60 questions, to be answered within 120 min. RESULTS: The SCT of 20 case vignettes with three nested questions were tested on 99 residents from the junior, intermediate, and senior residents, compared to answers from the expert group consisting of ten anesthesiology consultants with more than 5 years of experience. There were significant differences in mean SCT scores in the junior, intermediate, senior and expert groups, 59.3 (46.1-72.8), 64.7 (39.9-74.9), 67.5 (50.6-78.3), and 79.6 (78.4-84.8); p < 0,001 consecutively. Cronbach Alpha 0.69 was obtained, indicating good reliability. CONCLUSION: Our SCT was proven to be a valid and reliable test instrument to assess the clinical reasoning in airway management for anesthesiology residents. SCT was able to discriminate between groups of different clinical experiences and should be included to evaluate airway competencies in anesthesiology residents.

In situ simulation training for a better interprofessional team performance in transferring critically ill patients with COVID-19: a prospective randomised control trial.

BACKGROUND: Transferring critically ill patients with COVID-19 is a challenging task; therefore, well-trained medical team is needed. This study aimed to determine the role of in situ simulation training during pandemic by using high-fidelity manikin to improve interprofessional communication, skills and teamwork in transferring critically ill patients with COVID-19. METHODS: This single-blinded randomised control trial included 40 subjects allocated into standard low-fidelity simulator (LFS) and high-fidelity simulator (HFS) groups. Subjects, who were not members of multiprofessional team taking care of patients with COVID-19, in each group were assigned into small groups and joined an online interactive lecture session, two sessions of in-situ simulation and a debriefing session with strict health protocols. The first simulation aimed to teach participants the skills and steps needed. The second simulation aimed to assess transfer skills, communication and teamwork performance, that participants had learnt using a validated, comprehensive assessment tool. Data were analysed using unpaired t test or Mann-Whitney test. RESULTS: The HFS group showed significantly better overall transfer and communication skills than LFS group (89.70±4.65 vs 77.19±3.6, <0.05 and 100 vs 88.34 (63.33-100), p=0.022, respectively). The HFS group also demonstrated significantly better teamwork performance than the standard LFS group (90 (80-900) vs 80 (70-90), p=0.028). CONCLUSION: In situ simulation training using HFS significantly showed better performance than the standard training using LFS in regards to overall transfer and communication skills as well as teamwork performance. The training using HFS may provide a valuable adjunct to improve interprofessional skills, communication and teamwork performance in transferring critically ill patients with COVID-19.Trial registration numberNCT05113823.

Janus kinase (JAK)-inhibitors and coronavirus disease 2019 (Covid-19) outcomes: a systematic review and meta-analysis.

BACKGROUND: Currently, JAK-inhibitors are repurposed for therapy of Covid-19 because of their ability in restraining immune response, yet the corroboration regarding their advantage is still unclear. This study sought to analyze the efficacy of JAK-inhibitors to ameliorate the outcomes of Covid-19 sufferer.Research design and methods: Using specific keywords, we comprehensively go through the potential articles on ClinicalTrials.gov, Europe PMC, and PubMed sources until June 2nd, 2021. All published studies on JAK-inhibitors and Covid-19 were collected. RESULTS: There were 14 studies with 4,363 Covid-19 patients contained in the meta-analysis. Based on our data, we suggested that JAK-inhibitors corresponded with increased recovery rate (RR 1.17; 95%CI: 1.01-1.36, p= 0.040, I2 = 91%, random-effect modeling); shortened time to recovery (mean difference -0.96; 95%CI: -1.15, -0.77, p< 0.00001, I2 = 28%, random-effect modeling); reduction of clinical deterioration risk (RR 0.66; 95%CI: 0.48-0.89, p= 0.008, I2 = 57%, random-effect modeling); and reduction of Covid-19 mortality (RR 0.52; 95%CI: 0.36-0.76, p= 0.0006, I2 = 33%, random-effect modeling). CONCLUSIONS: This study propose that JAK-inhibitors perhaps provide advantageous effects on Covid-19 outcomes. JAK-inhibitors may be given during 1-2 weeks of disease to optimize its beneficial effects in halting the exaggerated immune response.

Umbilical cord mesenchymal stromal cells as critical COVID-19 adjuvant therapy: A randomized controlled trial.

One of the main causes of acute respiratory distress syndrome in coronavirus disease 2019 (COVID-19) is cytokine storm, although the exact cause is still unknown. Umbilical cord mesenchymal stromal cells (UC-MSCs) influence proinflammatory T-helper 2 (Th2 ) cells to shift to an anti-inflammatory agent. To investigate efficacy of UC-MSC administration as adjuvant therapy in critically ill patients with COVID-19, we conducted a double-blind, multicentered, randomized controlled trial at four COVID-19 referral hospitals in Jakarta, Indonesia. This study included 40 randomly allocated critically ill patients with COVID-19; 20 patients received an intravenous infusion of 1 × 106 /kg body weight UC-MSCs in 100 ml saline (0.9%) solution (SS) and 20 patients received 100 ml 0.9% SS as the control group. All patients received standard therapy. The primary outcome was measured by survival rate and/or length of ventilator usage. The secondary outcome was measured by clinical and laboratory improvement, with serious adverse events. Our study showed the survival rate in the UC-MSCs group was 2.5 times higher than that in the control group (P = .047), which is 10 patients and 4 patients in the UC-MSCs and control groups, respectively. In patients with comorbidities, UC-MSC administration increased the survival rate by 4.5 times compared with controls. The length of stay in the intensive care unit and ventilator usage were not statistically significant, and no adverse events were reported. The application of infusion UC-MSCs significantly decreased interleukin 6 in the recovered patients (P = .023). Therefore, application of intravenous UC-MSCs as adjuvant treatment for critically ill patients with COVID-19 increases the survival rate by modulating the immune system toward an anti-inflammatory state.

Nonconvulsive Status Epilepticus in Metabolic Encephalopathy in Indonesia Referral Hospital.

BACKGROUND: Nonconvulsive status epilepticus (NCSE) is often underdiagnosed in patients with metabolic encephalopathy (ME). The diagnosis of ME should be made specifically to recognize the underlying etiology. Delay in seizure identification and making a diagnosis of NCSE contributed to the poor outcome. OBJECTIVE: This study aimed to find the incidence and outcome of NCSE in patients with ME. METHODS AND MATERIAL: This was an observational prospective cross-sectional study in patients with ME in emergency and critical care units in Cipto Mangunkusumo General Hospital. The diagnosis of NCSE was based on EEG using Salzburg Criteria for Nonconvulsive Status Epilepticus (SCNC). The outcome was assessed within 30 days after the NCSE diagnosis has been made. RESULTS: A total of 50 patients with ME were involved in this study. NCSE was confirmed in 32 subjects (64%). The most common etiology of ME was sepsis (58%). The mortality rate in the NCSE and non-NCSE group was 40.6% vs 44.4%. Multiple aetiologies were risk factors to poor outcome in the NCSE group. CONCLUSIONS: The incidence of NCSE among patients with ME at our hospital was high. Despite the anti-epileptic treatment of the NCSE group, the underlying cause of ME is still the main factor that affected the outcome. Therefore, aggressive treatment of anti-epileptic drug (AED) should be very carefully considered knowing the possible side-effect that might worsen the outcome of patients with ME.

Diaphragm muscle thinning in mechanically ventilated critically ill patients.

OBJECTIVE: The aim of this study was to investigate the course of diaphragm changes in mechanically ventilated patients in ICU after four days of mechanical ventilation. In addition, to evaluate correlation of various demographic variables to baseline diaphragm muscle thickness and their effects on the course of diaphragm muscle thickness changes. METHODS: This study was conducted from December 2018 to February 2019 at Cipto Mangunkusumo National Hospital. Thirty critically ill patients using mechanical ventilation in the ICU were included. Baseline demographic data were collected. Baseline end expiratory diaphragm thickness was measured within one hour after starting mechanical ventilation and repeated every 24 hours for four days. Mortality and duration of mechanical ventilation were recorded. RESULTS: There were no differences in baseline diaphragm thickness according to gender, body mass index and modified Rankin Score. The subjects were divided into two categories: duration of mechanical ventilation less than seven days and duration of ventilation of seven days or more. The mean baseline diaphragm thickness was 2.11 + 0.15 mm. A rapid decrease of diaphragm muscle thickness was found within 24 hours. Diaphragm muscle thickness changed over subsequent measurements during observation. It was found that rapid diaphragm muscle thinning corresponded with longer duration of mechanical ventilation and worse outcomes. CONCLUSIONS: Diaphragm muscle thinning was seen early in the course of mechanical ventilation. Diaphragm muscle thickness changed over time, and there was no correlation with other measured variables.

Effectivity of benzydamine hydrochloride gargle to reduce propofol consumption in endoscopic retrograde cholangiopancreatography procedure: a randomized controlled trial.

BACKGROUND: Endoscopic Retrograde Cholangiopancreatography (ERCP) is a complex endoscopic procedure that requires moderate to deep sedation. Propofol is the sedative agent of choice for sedation in ERCP due to its fast distribution and fast elimination time without a cumulative effect after infusion, resulting in shorter recovery time. Benzydamine hydrochloride is a topical non-steroidal anti-inflammatory drug that has analgesic, local anesthetic, and anti-inflammatory effects that have been known to be effective in reducing postoperative sore throat. Combination of propofol and topical analgesic may provide adequate sedation and reduce propofol consumption. This study aimed to determine the effectivity of benzydamine hydrochloride gargling in reducing propofol consumption in the ERCP procedure. METHODS: This study was a single-blind randomized controlled trial for patients undergoing ERCP procedures at Cipto Mangunkusumo Hospital from August to September 2018. A total of 72 subjects were recruited consecutively and randomly assigned into two groups. The first group received 15 mL of 0.15% benzydamine hydrochloride mouthwash prior to the procedure, whereas the second group received 15 mL of water mouthwash. Additional propofol was administered when patient moved or Ramsay Sedation Scale rose above 4. Cumulative propofol consumption per kg body weight per minute and incidence of postoperative sore throat were recorded in each group. Incidence of desaturation, postoperative nausea vomitting, and dysphagia were also recorded. Data analysis was performed with Statistical Package for the Social Sciences. RESULTS: Cumulative propofol consumption per minute per kg body weight in the benzydamine hydrochloride group was 152.7 (91.9-238.8) mcg/kg/minute, while in the control group was 200.05 (114.4-380.2) mcg/kg/ minute (p = < 0.001). The incidence of sore throat on the 0th, 2nd, and 4th hour for the benzydamine hydrochloride group was 11.4, 11.4, and 5.7%, while in the control group was 50, 52.8, and 36.1% (p = < 0.001, < 0.001, 0.003). Desaturation was found in control group whereas none in benzydamine hydrochloride group. Complaints of nausea and vomiting were comparable in both groups. CONCLUSION: Benzydamine hydrochloride gargling was effective in reducing cumulative propofol consumption in the ERCP procedure. TRIAL REGISTRATION: Study was registered retrospectively in ClinicalTrials.gov with NCT04167592 on November 8th 2019.

A Comparative Study of Fractionated Versus Single Dose Injection for Spinal Anesthesia During Cesarean Section in Patients with Pregnancy-Induced Hypertension.

BACKGROUND: Local anesthetics for spinal anesthesia in one-single injection are known to induce more severe hypotension than a fractionated dose in healthy obstetric patients. Hypotension in obstetric patients with pregnancy-induced hypertension, including preeclampsia, during spinal anesthesia, could compromise fetal well-being. OBJECTIVES: This study aimed to compare the mean arterial pressure (MAP), the total dose of ephedrine required, and level of sensory blockade between the fractionated-dose and single-dose spinal anesthesia injection in obstetric patients with pregnancy-induced hypertension who underwent a cesarean section. METHODS: This single-blind randomized clinical trial was conducted from January to April 2018 after being approved by the Research Ethics Committee of Universitas Indonesia (No. 1174/UN2.F1/ETIK/2017) and recorded at ClinicalTrials.gov (NCT03693638). After obtaining informed consent, 42 parturients with hypertension in pregnancy (gestational hypertension or preeclampsia), ASA II-III, aged 18 - 40 years, and BMI of 18.5 - 35 kg/m2 with singleton pregnancy, who were planned for spinal anesthesia for emergency or semi-emergency cesarean section with hyperbaric bupivacaine 0.5% (MarcaineTM, Hospira) and fentanyl, were included in this study. All subjects were randomly divided into two groups including fractionated-dose (FD) and single-dose (SD). RESULTS: There was no significant difference between the two groups in MAP in the first 15 minutes after anesthesia (P > 0.05) and median total dose of ephedrine required (10 (0 - 25) mg in the FD group vs. 15 (0 - 30) mg in the SD group, P = 0.30). However, in the FD group, MAP tended to be higher in the first three minutes compared to the SD group. The level of sensory blockade was mostly at T4, which was not significantly different between the groups (52.4% in FD vs. 42.9% in SD, P = 0.59). CONCLUSIONS: In obstetric patients with pregnancy-induced hypertension who underwent a cesarean section, the mean arterial pressure after spinal anesthesia was not significantly different between the fractionated dose of spinal anesthesia injection and single-dose injection. Total ephedrine required and levels of sensory blockade were not significantly different between the groups.

The Effectiveness of 2% Lidocaine Gel Compared to 0.5% Tetracaine Eye Drop As Topical Anesthetic Agent for Phacoemulsification Surgery.

BACKGROUND: Topical anesthetics have become the primary choice in phacoemulsification procedures for cataract extraction. The most common topical anesthetic drug used is 0.5% tetracaine eye drops. Repeated administration of 0.5% tetracaine drops can cause corneal epithelial damage. Two percent lidocaine gel is latest option which has longer contact time with corneal epithelium. OBJECTIVES: To compare the effectiveness of 2% lidocaine gel with 0.5% tetracaine drops in phacoemulsification surgery. METHODS: The study was a single blinded randomized clinical trial from March to July 2017 in patients underwent phacoemulsification cataract surgery. There were 72 subjects with age ≥ 40 years old who received randomization and divided into 2 groups: 2% lidocaine gel group and 0.5% tetracaine eye drop group. Topical anesthetics were applied 5 minutes before surgery. Five minutes after surgery, pain scale perceived during surgery was assessed by using a numerical rating scale. At the end of surgery, the subject filled the satisfaction questionnaire on topical anesthetic drugs administered. The ophthalmologists were also given a satisfactory questionnaire for topical anesthetic drugs selected for the procedure. RESULTS: The median pain scale for 2% lidocaine gel group pain scale was 1; meanwhile, the median pain scale for 0.5% tetracaine eye drops was 3 (P < 0.05). CONCLUSIONS: Two percent lidocaine gel was more effective in relieving pain during phacoemulsification cataract surgery compared with 0.5% tetracaine drops.

Underutilization of anticoagulant for venous thromboembolism prophylaxis in three hospitals in Jakarta.

AIM: to assess the current use of anticoagulants and implementation of International Guidelines in venous thromboembolism (VTE) prophylaxis in hospitalized patients with acute medical illnesses in Jakarta, Indonesia. METHODS: a multicenter, prospective, disease registry, recruiting patients diagnosed as acutely ill medical diseases and other medical conditions at risk of VTE, with in-hospital immobilization for at least 3 days. RESULTS: of 401 patients, 46.9% received anticoagulants which included unfractionated heparin (64.4%), fondaparinux (11.7%), enoxaparin (9.6%), warfarin (3.7%), and combination of anticoagulants (10.6%). VTE prophylaxis using physical and mechanical method was used in 81.3% of patients, either as a single modality or in combination with anticoagulants. During hospitalization, VTE were found in 3.2% patients; 10 patients (2.5%) had lower limb events and 3 patients (0.75%) had a suspected pulmonary embolism. The main reference international guidelines used were AHA/ASA 2007 (47.4%), followed by ACCP 2008 (21.7%). CONCLUSION: the study showed underutilization of prophylaxis anticoagulants in which mechanical thromboprophylaxis either alone or combination with anticoagulants was the most commonly used. Unfractionated heparin was the preferable choice. The most commonly used guideline was AHA/ASA 2007. VTE thromboprophylaxis in medically ill patients needs to be encouraged.