Scoring systems, expert assessment, and identification of risk factors for the emergence of delirium in paediatric patients: Prospective cohort study.

INTRODUCTION: Emergence delirium (ED) is a transient irritative and dissociative state that arises after the cessation of anaesthesia in patients who do not respond to calming measures. There are many risk factors for ED, but the exact cause and underlying mechanism have not been determined because the definition of ED is still unclear in consensus. This study aims to determine ED incidence, identify ED risk factors and external validation of Watcha, Cravero and expert assessment to Pediatric Anesthesia Emergence Delirium (PAED) scoring system in ED prediction. MATERIALS AND METHODS: This study is a prospective cohort study on 79 paediatrics who underwent elective surgery with general anaesthesia. Parameter measures include the incidence of ED, ED risk factors, and the relationship between PAED, Watcha, Cravero score and expert assessment. The ED risk factor was analysed using univariate and multivariate analysis. The relationship between PAED, Watcha, Cravero score, and expert assessment was determined using Receiver Operating Characteristic (ROC) curve analysis. RESULTS: The incidence of ED was 22.8%. All parameters examined in this study showed p < 0.05. Watcha's scoring correlates with the PAED scoring and shows the highest discrimination ability with AUC 0.741 and p < 0.05. CONCLUSION: The incidence of ED in paediatrics is relatively high. Compared to others, Watcha score are more reliable for ED prediction. However, some demographic and perioperative factors are not the risk factor of ED.

Predictive accuracy of the APACHE IV scores on mortality and prolonged stay in the intensive care unit of Dr Sardjito Hospital.

INTRODUCTION: Acute Physiology and Chronic Health Evaluation (APACHE) is the most widely used scoring system in the intensive care unit (ICU). The APACHE IV showed a good level of discrimination and calibration on predicting mortality and prolonged stay (PLOS) in some countries. This study is aimed to determine the predictive accuracy of the APACHE IV score on mortality and PLOS at the ICU of Dr Sardjito General Hospital (SGH). MATERIALS AND METHODS: This study involved all adult patients at the ICU of SGH during 2018 that met the inclusion criteria. The discrimination of APACHE IV scores on mortality and PLOS was analyzed with Receiver Operating Characteristic Curve, and the optimal cut-off point was assessed with the Youden Index. The calibration of the APACHE IV score was assessed with the Hosmer-Lemeshow goodness-of-fit test, and a p-value of >0.05 is considered a good calibration. RESULTS: From the data of 742 patients, only 476 were included. The overall mortality and PLOS rate was 25.4 % and 15.1 %, respectively. The mean of APACHE IV score was 66.27±27.7. The area under the receiving curve with a 95% confidence interval for mortality is 0.99(0.97-1.00) and for PLOS was 0.68(0.62-0.74). The optimal cut-off point of the APACHE IV score for mortality was 78.9, with a sensitivity of 0.96 and a specificity of 0.96. The optimal cut-off point of the APACHE IV score for PLOS is 62.5 (in the 6th percentiles), with a sensitivity of 0.72 and a specificity of 0.61. The calibration is good for mortality prediction (p=0.98) but is poor for PLOS prediction (p=0.01). CONCLUSION: APACHE IV score has excellent accuracy for mortality prediction but is poor for PLOS prediction in patients in the ICU of SGH.

Incidence of consciousness in pediatric patients during Methotrexate injection with monitored anesthesia care.

BACKGROUND: Procedural sedation and analgesia (PSAA) or monitoring anaesthesia care (MAC) must provide analgesia, amnesia and hypnosis with complete and rapid recovery that suits a particular operative procedure with minimum side effects. For a child undergoing a procedure, a major deciding factor is whether it is painful or not. Deep Sedation is required during the procedures to allay the anxiety, pain, and movement. The appropriate level of sedation depth will prevent consciousness, over-sedation, optimisation of dosage and prevents adverse complications. There are few studies about consciousness in pediatric patients during methotrexate injection with monitored anaesthesia care (MAC). The objective is to find out the incidence of consciousness of paediatric patients during methotrexate injection with Monitored Anaesthesia Care. METHODS: Observational study conducted on 68 patients (1- 18 yrs.) with physical status of ASA II during methotrexate injection with MAC at the RSUP dr. Sardjito. The depth of anaesthesia was monitored with Observer's Alertness Assessment Sedation Scale (OAAS) every two minutes. Consciousness was defined as OAAS=5, or if there is volunteer movement of patients. The result was analysed and categorised according to age, sex, physical status, Body Mass Index (BMI) and anaesthesia's medication of patients. RESULTS: Positive consciousness in paediatric patients based on OASS score at 2-minute and 4-minutes was 26.5% and 3.2% respectively, and was rescued by additional propofol 2mg/kg body weight. CONCLUSION: The incidence of paediatric consciousness in patients during methotrexate injection with Monitored Anaesthesia Care (MAC) in the Sardjito General Hospital is 26.5% (2-minute after induction) and 3.2% (4-minute after induction), and this is considerably high thus needing futher prevention.

Pre-operative and intraoperative determinants for prolonged ventilation following adult cardiac surgery.

BACKGROUND: Prolonged ventilation is a serious complication after cardiac surgery, but few risk prediction models exist. Our objectives were to develop a specific risk prediction model based on pre-operative variables, to identify whether selected intraoperative variables could improve prediction, and to compare our model with the EuroSCORE. METHODS: Data from 5027 patients undergoing open-heart surgery in 2000-2007 were used for logistic regression model development. Internal validation was performed by bootstrapping. Discrimination and calibration were assessed with areas under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test. Our pre-operative model was compared with predictions based on the additive and logistic EuroSCORE. RESULTS: Age, previous cardiac surgery, peripheral arterial disease, left ventricular hypertrophy, chronic pulmonary disease, renal insufficiency, pre-operative hemoglobin concentration, urgent or emergency operation, and operation other than isolated coronary artery bypass grafting were identified as pre-operative predictors for prolonged ventilation (model I). Discrimination and accuracy were excellent (AUC: 0.848 and shrinkage factor: 94%). Calibration was good (Hosmer-Lemeshow test: P = 0.43). Inclusion of a few intraoperative variables somewhat improved the model, increasing shrinkage factors (96%) and discrimination ability (AUC model II = 0.870 and model III = 0.875 for two alternative such models). Our pre-operative model showed better performance than the logistic or additive EuroSCORE. CONCLUSIONS: The pre-operative risk prediction model for prolonged ventilation with easily obtainable variables in routine clinical work performed well and was only slightly improved by inclusion of intraoperative variables. Performance was better than with the EuroSCORE.

Asaia bogorensis gen. nov., sp. nov., an unusual acetic acid bacterium in the alpha-Proteobacteria.

Eight Gram-negative, aerobic, rod-shaped and peritrichously flagellated strains were isolated from flowers of the orchid tree (Bauhinia purpurea) and of plumbago (Plumbago auriculata), and from fermented glutinous rice, all collected in Indonesia. The enrichment culture approach for acetic acid bacteria was employed, involving use of sorbitol medium at pH 3.5. All isolates grew well at pH 3.0 and 30 degrees C. They did not oxidize ethanol to acetic acid except for one strain that oxidized ethanol weakly, and 0.35% acetic acid inhibited their growth completely. However, they oxidized acetate and lactate to carbon dioxide and water. The isolates grew well on mannitol agar and on glutamate agar, and assimilated ammonium sulfate for growth on vitamin-free glucose medium. The isolates produced acid from D-glucose, D-fructose, L-sorbose, dulcitol and glycerol. The quinone system was Q-10. DNA base composition ranged from 59.3 to 61.0 mol% G + C. Studies of DNA relatedness showed that the isolates constitute a single species. Phylogenetic analysis based on their 16S rRNA gene sequences indicated that the isolates are located in the acetic acid bacteria lineage, but distant from the genera Acetobacter, Gluconobacter, Acidomonas and Gluconacetobacter. On the basis of the above characteristics, the name Asaia bogorensis gen. nov., sp. nov. is proposed for these isolates. The type strain is isolate 71T (= NRIC 0311T = JCM 10569T).

Interactions between rumen anaerobic fungi and ciliate protozoa in the degradation of rice straw cell walls.

Suspensions of mixed rumen protozoa were added to incubations of the anaerobic fungus Neocallimastix patriciarum with rice straw cell walls. The protozoa did not influence the dry matter lost from the straw, or the solubilization of monosaccharides, but they had a marked effect on the fermentation products formed. Studies with 14C-labelled protozoa suggested that the presence of protozoa reduced the fungal carboxymethylcellulase activity to around half of that found in pure cultures of the fungus.